[Federal Register Volume 64, Number 88 (Friday, May 7, 1999)]
[Proposed Rules]
[Pages 24716-24854]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-11200]



[[Page 24715]]

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Part II





Department of Health and Human Services





_______________________________________________________________________



Health Care Financing Administration



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42 CFR Parts 412, 413, 483, and 485



Medicare Program; Changes to the Hospital Inpatient Prospective Payment 
Systems and Fiscal Year 2000 Rates; Proposed Rule

  Federal Register / Vol. 64, No. 88 / Friday, May 7, 1999 / Proposed 
Rules  

[[Page 24716]]



DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 412, 413, 483, and 485

[HCFA-1053-P]
RIN 0938-AJ50


Medicare Program; Changes to the Hospital Inpatient Prospective 
Payment Systems and Fiscal Year 2000 Rates

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Proposed rule.

-----------------------------------------------------------------------

SUMMARY: We are proposing to revise the Medicare hospital inpatient 
prospective payment systems for operating costs and capital-related 
costs to implement 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, 1999. We also are setting 
forth proposed rate-of-increase limits as well as proposed policy 
changes for hospitals and hospital units excluded from the prospective 
payment systems. Finally, we are proposing changes to the policies 
governing payment to hospitals for the direct costs of graduate medical 
education.

DATES: Comments will be considered if received at the appropriate 
address, as provided below, no later than 5 p.m. on July 6, 1999.

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-1053-P P.O. Box 7517, 
Baltimore, MD 21207.
    If you prefer, you may deliver your written comments (an original 
and three copies) to one of the following addresses:

Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW, 
Washington, DC 20201, or
Room C5-11-03, Central Building, 7500 Security Boulevard, Baltimore, MD 
21244-1850

FOR FURTHER INFORMATION CONTACT:
Steve Phillips, (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:

Comments, Procedures, Availability of Copies, and Electronic Access

    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code HCFA-1053-P. Comments received timely will be available 
for public inspection as they are received, generally beginning 
approximately 3 weeks after publication of a document, in Room 445-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
Health Care Financing Administration, Office of Information Services, 
Security Standards Group, Division of HCFA Enterprise Standards, Room 
N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 
Attn: John Burke HCFA-1053-P.

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I. Background

A. Summary

    Section 1886(d) of the Social Security Act (the Act) sets 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 hospital units are excluded from the prospective payment 
system: 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 hospital's 
number of 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 and hospital units are located in parts 
412 and 413, and the GME regulations are located in part 413.
    On July 31, 1998, we published a final rule in the Federal Register 
(63 FR 40954) that implemented both statutory requirements and other 
changes to the Medicare hospital inpatient prospective

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payment systems for both operating costs and capital-related costs, as 
well as changes addressing payment for excluded hospitals and payments 
for GME costs. Generally, these changes were effective for discharges 
occurring on or after October 1, 1998.
    In addition, on February 25, 1999, we published in the Federal 
Register (64 FR 9378) a final rule that implemented revised wage index 
values, geographic adjustment factors, operating standardized amounts, 
and capital Federal rates for hospitals subject to the inpatient 
hospital prospective payment system. These changes are effective for 
discharges occurring on or after March 1, 1999.

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. We also are proposing 
changes concerning GME costs and excluded hospitals and units, 
including critical access hospitals (CAHs). This proposed rule would be 
effective for discharges occurring on or after October 1, 1999.
    We note that the efforts that we are undertaking to make the 
Medicare computer systems compliant on January 1, 2000, will not delay 
our ability to make timely and updated payments to hospitals under the 
FY 2000 prospective payment system final rule that will follow this 
proposed rule. The following is a summary of the major changes that we 
are proposing to make.
1. Proposed Changes to the DRG Reclassifications and Recalibrations of 
Relative Weights
    Section 1886(d)(4)(C) of the Act requires us to adjust the DRG 
classifications and relative weights at least annually. In order to 
avoid compromising our ability to process and pay hospital claims 
during the period leading up to and immediately following January 1, 
2000, we are not implementing any revisions to the International 
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-
9-CM) coding system. The changes that we are proposing to make relating 
to DRG reclassifications and recalibrations for FY 2000 are set forth 
in section II of is preamble.
2. Proposed 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:
     The FY 2000 wage index update, using FY 1996 wage data.
     The exclusion from the wage index of Part A physician wage 
costs that are teaching-related, as well as resident and Part A 
certified registered nurse anesthetist (CRNA) costs.
     Revisions to the wage index based on hospital 
redesignations.
3. Other Decisions and Proposed 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 proposed 
changes concerning the following:
     Sole community hospitals.
     Rural referral centers.
     Indirect medical education adjustment.
     Medicare Geographic Classification Review Board (MGCRB) 
decisions.
     Direct GME programs.
4. Proposed Changes to the Prospective Payment System for Capital-
Related Costs
    In section V of this preamble, we discuss the special exceptions 
process for certain eligible hospitals to receive additional payments 
for major construction or renovation projects that began soon after the 
start of the capital prospective payment system.
5. Proposed Changes for Hospitals and Hospital Units Excluded From the 
Prospective Payment Systems
    In section VI of this preamble, we discuss the following proposals 
concerning excluded hospital and hospital units and CAHs:
     Limits on and adjustments to the proposed target amounts 
for FY 2000.
     Changes in bed size or status of excluded hospitals or 
hospital units.
     Payment for services furnished at satellite hospital 
locations.
     Responsibility for care of patients in hospitals within 
hospitals.
     The allowable emergency response time for CAHs located in 
frontier or other specifically defined remote areas.
     Compliance with minimum data set requirements by CAHs with 
swing bed approval.
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 2000 
prospective payment rates for operating costs and capital-related 
costs. We also address update factors for determining the rate-of-
increase limits for cost reporting periods beginning in FY 2000 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 2000 
capital cost model.
9. Report to Congress on the Update Factor for Hospitals under the 
Prospective Payment System and Hospitals and Units Excluded From the 
Prospective Payment System
    Section 1886(e)(3)(B) of the Act requires the Secretary to report 
to Congress on our initial estimate of a recommended update factor for 
FY 2000 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 2000 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
    Under section 1805(b) of the Act, the Medicare Payment Advisory 
Commission (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, 1999 report made several 
recommendations concerning hospital inpatient payment policies. These 
recommendations, and the action we are proposing to take with regard to 
them

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(when an action is recommended) are discussed in detail in this 
document. See section VII of this preamble for specific information. 
For further information relating specifically to the MedPAC March 1 
report or to obtain a copy of the report, contact MedPAC at (202) 653-
7220.

II. Proposed Changes to DRG Reclassifications and Recalibrations of 
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 
at least 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.
    As discussed in more detail in section II.B.8 of this preamble, we 
are not implementing any revisions to the ICD-9-CM codes. We have 
undertaken, and continue to undertake, major efforts to ensure that all 
of the Medicare computer systems are ready to function on January 1, 
2000. If we were to implement changes to the ICD-9-CM codes on October 
1, 1999, we would endanger the functioning of the Medicare computer 
systems, and, specifically, we might compromise our ability to process 
hospital bills. We can, however, reclassify existing codes into 
different DRGs, if appropriate. The proposed changes to the DRG 
classification system, and the proposed recalibration of the DRG 
weights for discharges occurring on or after October 1, 1999, are 
discussed below.

B. DRG Reclassification

1. General
    Cases are classified into DRGs for payment under the prospective 
payment system based on the principal diagnosis, up to eight additional 
diagnoses, and up to six procedures performed during the stay, as well 
as age, sex, and discharge status of the patient. The diagnosis and 
procedure information is reported by the hospital using ICD-9-CM codes. 
The Medicare fiscal intermediary enters the information into its claims 
processing 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 499 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 transplants (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 (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 2000 and other decisions concerning DRGs are set forth 
below.
2. MDC 15 (Newborns and Other Neonates with Conditions Originating in 
the Perinatal Period)
    Based on inquiries we have received, we reviewed the 
appropriateness of including diagnosis codes V29.2 (Newborn observation 
for suspected respiratory condition) and V29.3 (Newborn observation for 
other genetic problem) in the list of allowable secondary diagnoses 
under DRG 391 (Normal Newborn). Currently, when one of these codes is 
the only secondary diagnosis for an otherwise healthy newborn, the case 
is assigned to DRG 390 (Neonate with Other Significant Problems).
    Diagnosis codes V29.2 and V29.3 are used to indicate that the 
newborn was observed for a suspected condition but none was found. 
Other newborn observation codes in this series (V29.0, V29.1, V29.8, 
and V29.9) are included in the allowable secondary diagnoses under DRG 
391. We believe that the presence of diagnosis code V29.2 or V29.3 
should not exclude a newborn from being classified as normal. 
Therefore, we are proposing to include diagnosis codes V29.2 and V29.3 
in the list of allowable secondary diagnosis under DRG 391.
3. MDC 19 (Mental Diseases and Disorders)
    We have received correspondence about the title of DRG 425, ``Acute 
Adjustment Reaction and Disturbances of Psychosocial Dysfunction'' 
under MDC 19. The correspondents state that the use of the terms 
``disturbances'' and ``dysfunction'' is redundant since the terms have 
similar meanings. They suggested that we remove the term 
``disturbances.''
    We agree with the correspondents and are proposing to revise the 
title of DRG 425 to read ``Acute Adjustment Reaction and Psychological 
Dysfunction.''

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4. MDC 22 (Burns)
    In the FY 1999 final prospective payment system rule that was 
effective October 1, 1998 (63 FR 40957), we implemented an extensive 
redesign of the DRGs for burns to more appropriately capture the 
variation in resource use associated with different classes of burn 
patients. The redesigned DRGs, 504 through 511, are split on such 
factors as whether there is an extensive burn, a full-thickness burn, 
or an inhalation injury, as well as other factors such as skin graft, 
trauma, or presence of a CC. DRGs 504 and 505 are assigned to cases 
with extensive third degree burns; that is, cases in which the burns 
cover at least 20 percent of body surface area combined with a third 
degree burn covering at least 10 percent of body surface area. DRGs 506 
through 509 are assigned to all other cases with full-thickness burns 
(that is, a third degree burn). Finally, DRGs 510 and 511 are assigned 
to cases with nonextensive burns (that is, only first and second degree 
burns).
    After these DRGs went into effect on October 1, 1998, we were 
contacted by several hospitals about our inclusion of the following 
codes as full-thickness burns:

948.00  Body burn involving less than 10 percent of body surface, 
third degree less than 10 percent or unspecified
948.10  Body burn involving 10 to 19 percent of body surface, third 
degree less than 10 percent or unspecified
948.20  Body burn involving 20 to 29 percent of body surface, third 
degree less than 10 percent or unspecified
948.30  Body burn involving 30 to 39 percent of body surface, third 
degree less than 10 percent or unspecified
948.40  Body burn involving 40 to 49 percent of body surface, third 
degree less than 10 percent or unspecified
948.50  Body burn involving 50 to 59 percent of body surface, third 
degree less than 10 percent or unspecified
948.60  Body burn involving 60 to 69 percent of body surface, third 
degree less than 10 percent or unspecified
948.70  Body burn involving 70 to 79 percent of body surface, third 
degree less than 10 percent or unspecified
948.80  Body burn involving 80 to 89 percent of body surface, third 
degree less than 10 percent or unspecified
948.90  Body burn involving 90 percent or more of body surface, 
third degree less than 10 percent or unspecified

    The hospitals are concerned that the use of the fifth digit ``0'' 
on codes 948.10 through 948.90 can capture cases in which there 
actually is no third degree burn. The hospitals requested that we 
consider removing from the full-thickness burn DRGs 506 through 509 all 
codes in the 948 category with a fifth digit of ``0''.
    We agree that the codes in category 948 with a fifth digit of ``0'' 
should not be assigned to DRGs 506 through 509 as full-thickness burns 
since not all of these cases will have a third degree burn. Therefore, 
we are proposing to remove these codes from DRGs 506 through 509 and to 
add them to DRG 510 (Nonextensive Burns with CC or Significant Trauma) 
and DRG 511 (Nonextensive Burns without CC or Significant Trauma).
    If a case with a code of 948.10 is a full-thickness burn, this 
information would be captured in the burn code for the site of the burn 
(for example, 943.35 (Third degree burn of shoulder)) and the case 
would be correctly assigned to a full-thickness burn DRG. Hospitals 
have been instructed in Coding Clinic for ICD-9-CM, Fourth Quarter, 
1994 (pages 22 through 28) to code the site of the burn first (940 
through 947), when known. Codes from category 948 may be used as a 
principal diagnosis only when the site of the burn is not specified. 
Category 948 is used as an additional code to provide information on 
the percentage of total body that is burned or to show the percentage 
of burn that was third degree. When hospitals report codes properly, 
full-thickness burns will be assigned to a code for burn of the 
specific site (940 through 947). This site code also shows the degree 
of the burn. Furthermore, for those rare cases where the site is not 
provided, but it is known that 10 percent or more of the body has a 
third degree burn, hospitals may report this information through the 
use of category 948 with a fifth digit of ``1'' through ``9''. All of 
these cases will be classified as full-thickness burns in DRGs 506 
through 509. Therefore, our proposal to remove codes 948.1 through 
948.9 with a fifth digit of ``0'' will not prevent cases from being 
assigned to one of the full-thickness DRGs when there is a third degree 
burn and the case is correctly coded.
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

[[Page 24720]]

DRGs in that surgical class may be higher than that for other surgical 
classes in the MDC. The ``other OR procedures'' class is a group of 
procedures that are least likely to be related to the diagnoses in the 
MDC but are occasionally performed on patients with these diagnoses. 
Therefore, these procedures should only be considered if no other 
procedure more closely related to the diagnoses in the MDC has been 
performed.
    A second example occurs when the difference between the average 
weights for two surgical classes is very small. We have found that 
small differences generally do not warrant reordering of the hierarchy 
since, by virtue of the hierarchy change, the relative weights are 
likely to shift such that the higher-ordered surgical class has a lower 
average weight than the class ordered below it.
    Based on the preliminary recalibration of the DRGs, we are 
proposing to modify the surgical hierarchy as set forth below. As we 
stated in the September 1, 1989 final rule (54 FR 36457), we are unable 
to test the effects of proposed revisions to the surgical hierarchy and 
to reflect these changes in the proposed relative weights due to the 
unavailability of revised GROUPER software at the time the proposed 
rule is prepared. Rather, we simulate most major classification changes 
to approximate the placement of cases under the proposed 
reclassification and then determine the average charge for each DRG. 
These average charges then serve as our best estimate of relative 
resource use for each surgical class. We test the proposed surgical 
hierarchy changes after the revised GROUPER is received and reflect the 
final changes in the DRG relative weights in the final rule. Further, 
as discussed 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 propose to revise the surgical hierarchy for the 
Pre-MDC DRGs and MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth 
and Throat) as follows:
     In the Pre-MDC DRGs, we would reorder Lung Transplant (DRG 
495) above Bone Marrow Transplant (DRG 481).
     In MDC 3, we would reorder Tonsil and Adenoid Procedure 
Except Tonsillectomy and/or Adenoidectomy Only (DRGs 57 and 58) above 
Cleft Lip and Palate Repair (DRG 52).
    6. Refinement of Complications and Comorbidities (CC) 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); the August 29, 1997 final 
rule for the FY 1998 revisions (62 FR 45966); and the July 31, 1998 
final rule for the FY 1999 revisions (63 FR 40954)). We are not 
proposing to add or delete any codes from the CC list.
    In addition, as discussed in detail in section II.B.8 of this 
preamble, because we are not making changes to the ICD-9-CM codes for 
FY 2000, we do not need to modify the current list for new or deleted 
codes. Therefore, there are no proposed revisions to the CC Exclusions 
List for FY 2000.
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

[[Page 24721]]

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, and 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.) No procedures were moved in FY 1999, as noted in the 
July 31, 1998 final rule (63 FR 40962).
    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 identified several procedures that we 
are proposing to move from DRG 468 to one of the surgical DRGs. We did 
not identify any necessary changes in procedures under DRG 477 and are, 
therefore, not proposing to move any procedures from DRG 477 to one of 
the surgical DRGs.
    First, we are proposing to move three codes from DRG 468 to MDC 1 
(Diseases and Disorders of the Nervous System), all of which would be 
assigned to DRGs 7 and 8 (Peripheral and Cranial Nerve and Other 
Nervous System Procedure).\1\ Procedure code 38.7 (Interruption of the 
vena cava) is sometimes performed in conjunction with treatment for the 
principal diagnosis 434.11 (Cerebral embolism with infarction), which 
is assigned to MDC 1. Under the current configuration, procedure code 
38.7 is not assigned to MDC 1. Therefore when this procedure is 
performed by a neurological condition, such as a cerebral embolism with 
infarction, the discharge does not group to one of the surgical DRGs 
within MDC 1. It is assigned instead to DRG 468 as an unrelated 
procedure. Since our medical advisors tell us that procedure code 38.7 
is appropriately performed for neurological conditions, we are 
proposing to add it to DRGs 7 and 8.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    Second, we are also proposing that procedure codes 83.92 (Insertion 
or replacement of skeletal muscle stimulator) and 83.93 (Removal of 
skeletal muscle stimulator) both be categorized with other procedures 
on the nervous system. These procedures can be performed on patients 
with a principal diagnosis in MDC 1, such as 344.00 (Quadriplegia 
unspecified) or 344.31 (Monoplegia of lower limb, affecting dominant 
side). Therefore, these two codes would also be assigned to DRGs 7 and 
8.
    Third, procedure code 39.50 (Angioplasty or atherectomy of 
noncoronary vessel) is not currently assigned to MDC 4 (Diseases and 
Disorders of the Respiratory System). This procedure can be performed 
for patients who develop pulmonary embolism. The principal diagnosis 
for pulmonary embolism is in MDC 4, and, to increase clinical 
coherence, we propose to add procedure code 39.50 to that MDC in DRGs 
76 and 77 (Other Respiratory System OR Procedures).
    Fourth, insertion of totally implantable infusion pump (procedure 
code 86.06) is not assigned to MDC 5 (Diseases and Disorders of the 
Circulatory System) in the current DRG configuration. Infusion pumps 
should be assigned to all MDCs where subcutaneous insertion of the pump 
is appropriate. Procedure code 86.06 may be performed on patients with 
a principal diagnosis in MDC 5 such as 451.83 (Phlebitis and 
thrombophlebitis of the deep veins of other extremities). Therefore, we 
are proposing to add procedure code 86.06 to DRG 120 (Other Circulatory 
System OR Procedures) in MDC 5.
    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 described 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, co-chaired by the National Center for 
Health Statistics (NCHS) and HCFA, that is charged with the mission of 
maintaining and updating the ICD-9-CM system. 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 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 field, such 
as the American Health Information Management Association (AHIMA) 
(formerly American Medical Record Association (AMRA)), the American 
Hospital Association (AHA), and various physician specialty groups as

[[Page 24722]]

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 for FY 2000 at 
public meetings held on June 14 and November 2, 1998. Even though the 
Committee conducted public meetings and considered approval of coding 
changes for FY 2000 implementation, we are not implementing any changes 
to ICD-9-CM codes for FY 2000. We have undertaken, and continue to 
undertake, major efforts to ensure that all of the Medicare computer 
systems are ready to function on January 1, 2000. If we were to make 
system changes to capture additions, deletions, and modifications to 
ICD-9-CM codes for FY 2000, we would endanger the functioning of the 
Medicare computer systems, and, specifically, we might compromise our 
ability to process hospital bills. Therefore, the code proposals 
presented at the public meetings held on June 14 and November 2, 1998, 
that (if approved) ordinarily would have been included as new codes for 
October 1, 1999, will not be included in this proposed rule. These code 
changes to ICD-9-CM will be considered for inclusion in the next annual 
update for FY 2001. The initial meeting for consideration of coding 
changes for implementation in FY 2001 will be held on May 13, 1999.
    Copies of the minutes of the 1998 meetings can be obtained from the 
HCFA Home Page at 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; C4-
07-07; 7500 Security Boulevard; Baltimore, Maryland 21244-1850. 
Comments may be sent by E-mail to: [email protected].
9. Other Issue: Implantation of Muscle Stimulator
    In the July 31, 1998 final rule, we responded to a comment on the 
DRG assignment for implantation of a muscle stimulator (63 FR 40964). 
In that document, we stated that we would readdress this issue after 
reviewing the FY 1998 MedPAR file.
    There is concern in the manufacturing industry that the current DRG 
assignment for the implantation of a muscle stimulator and the 
associated tendon transfer for quadriplegics is inappropriate. When the 
procedures are performed during two separate admissions, the tendon 
transfer (procedure code 82.56 (Other hand tendon transfer or 
transplantation)) is assigned to DRGs 7 and 8 and the insertion of the 
muscle stimulator (procedure code 83.92 (Insertion or replacement of 
skeletal muscle stimulator)) is assigned to DRG 468. However, when both 
procedures are performed in the same admission, the case is assigned to 
DRGs 7 and 8.
    As discussed in section II.B.7.a of this preamble, we are proposing 
to assign code 83.92 to DRGs 7 and 8 in MDC 1. Therefore, if a case 
involves either procedure code 82.56 or 83.92, or both procedure codes, 
the case would be assigned to DRGs 7 and 8.
    A presentation on one type of muscle stimulator was made by a 
device manufacturer before the ICD-9-CM Coordination and Maintenance 
Committee on November 2, 1998. The manufacturer strongly suggested that 
a new code assignment be made for the procedure for insertion of this 
stimulator and that it be placed in category 04.9 (Other operations on 
cranial and peripheral nerves). However, based on comments received by 
the Committee, there was an overwhelming response from the coding 
community that a new code should not be created. The commenters believe 
that these codes (82.56 and 83.92) adequately described the procedures 
since the patient receives a tendon transfer in addition to the 
skeletal muscle stimulator insertion. This is done so that the 
quadriplegic patient can achieve some hand grasping ability where there 
was none before. Some quadriplegic patients receive the tendon transfer 
on one admission and the stimulator insertion on a subsequent 
admission. Others have both procedures performed on the same admission. 
Since the tendon transfer and stimulator insertion are being performed 
on quadriplegic patients, a condition found in MDC 1, we propose to add 
procedure codes 82.56 and 83.92 to DRGs 7 and 8.

C. Recalibration of DRG Weights

    We are proposing to use the same basic methodology for the FY 2000 
recalibration as we did for FY 1999. (See the July 31, 1998 final rule 
(63 FR 40965).) That is, we would recalibrate the weights based on 
charge data for Medicare discharges. However, we propose to use the 
most current charge information available, the FY 1998 MedPAR file. 
(For the FY 1999 recalibration, we used the FY 1997 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 1998 MedPAR data, based on bills received by HCFA through December 
1998, from all hospitals subject to the prospective payment system and 
short-term acute care hospitals in waiver States. The FY 1998 MedPAR 
file includes data for approximately 11.2 million Medicare discharges.
    The methodology used to calculate the proposed DRG relative weights 
from the FY 1998 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 and 
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

[[Page 24723]]

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 1998 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 2000. Using the FY 1998 MedPAR 
data set, there are 39 DRGs that contain fewer than 10 cases. We 
computed the weights for the 39 low-volume DRGs by adjusting the FY 
1999 weights of these DRGs by the percentage change in the average 
weight of the cases in the other DRGs.
    The weights developed according to the methodology described above, 
using the proposed DRG classification changes, result in an average 
case weight that is different from the average case weight before 
recalibration. Therefore, the new weights are normalized by an 
adjustment factor, so that the average case weight after recalibration 
is equal to the average case weight before recalibration. This 
adjustment is intended to ensure that recalibration by itself neither 
increases 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.

D. Use of Non-MedPAR Data for Reclassification and Recalibration of the 
DRGs

1. Introduction
    As in past years, in the DRG reclassification and recalibration 
process for the FY 2000 proposed rule, we used the MedPAR file, which 
consists of data for approximately 11 million Medicare discharges. In 
the FY 1999 rulemaking process, we used the FY 1997 MedPAR file to 
recalibrate DRGs and evaluate possible changes to DRG classifications; 
for this FY 2000 proposed rule, we used the FY 1998 MedPAR file. The 
Conference Report that accompanied the Balanced Budget Act of 1997 
stated 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 Medicare Provider Analysis and Review (MedPAR) data in 
annually recalibrating and reclassifying the DRGs.'' (H. R. Conf. Rep. 
No. 105-217 at 734 (1997)).
    Consistent with that language, we considered non-MedPAR data both 
in the rulemaking process for FY 1999 and in developing this proposed 
rule. We received non-MedPAR data from entities on behalf of the 
manufacturer of a specific drug, platelet inhibitors; the manufacturer 
is seeking to obtain a new DRG assignment for cases involving platelet 
inhibitors. The non-MedPAR data purported to show cases involving 
platelet inhibitors. As discussed further below, we concluded it was 
not feasible to use the non-MedPAR data submitted to us because, among 
other things, we did not have information to verify that the cases 
actually involved the drug, nor did we have information to verify that 
the cases reflected a representative sample (and did not simply reflect 
high cost cases).
    Effective October 1, 1998, we implemented a code for platelet 
inhibitors, but until we receive bills for Medicare discharges 
occurring during FY 1999, the MedPAR data do not enable us to 
distinguish between cases with platelet inhibitors and cases without 
platelet inhibitors (63 FR 40963). Representatives of the 
pharmaceutical company first presented us with non-MedPAR data during 
the rulemaking process for FY 1999. The data was compiled by a health 
information company, and purported to show, for cases from a sample of 
hospitals, the average standardized charges (as calculated by the 
health information company) for different classes of patients.
    In the FY 1999 final rule, we stated a number of reasons why we 
rejected the non-MedPAR data we had received. First, we could not 
validate whether the data reflected Medicare beneficiaries. Second, the 
data came from a limited number of hospitals (83) having an information 
sharing contract with the health information company that compiled the 
database; the company failed to provide us with information that would 
enable us to verify whether the data reflected a representative sample 
of hospitals or claims. Third, for over 90 percent of the cases, the 
company failed to provide us with information on which hospital 
furnished the treatment. This means that we could not validate the data 
on standardized charges nor could we use the data to determine an 
appropriate DRG weight for the DRG from which the cases would be 
reclassified. For these reasons (and others), we concluded in the July 
31, 1998 final rule that we could not use the data to change the DRG 
assignment of cases involving platelet inhibitor drug therapy from DRG 
112 (Percutaneous Cardiovascular Pacemaker Procedures) to DRG 116 
(Other Permanent Cardiac Pacemaker Implant or PTCA with Coronary Artery 
Stent Implant).
    After publication of the July 31, 1998 final rule, we met and 
corresponded on several occasions with the manufacturers, vendors, and 
legal representatives of the pharmaceutical company in an effort to 
resolve data issues. We reiterated that, among other things, we needed 
to know for each case

[[Page 24724]]

the hospital that furnished the services. We have not received 
information necessary to validate the data itself or its 
representativeness.
    We remain open to considering non-MedPAR data in the DRG 
reclassification and recalibration process, but, consistent with the 
Conference Report, as well as our longstanding policies, the data must 
be ``reliable'' and ``validated.'' The July 31, 1998 final rule 
reflects the major factors that we consider in evaluating whether data 
are feasible, reliable, and validated, but we believe it might be 
useful to discuss these issues in greater detail.
2. The DRG Reclassification and Recalibration Process
    In order to understand whether it is feasible to use non-MedPAR 
data, and whether the data are reliable and validated, it is critical 
to understand the DRG recalibration and reclassification process. As 
described earlier, one of the first steps in the annual DRG 
recalibration is that the Medicare hospital inpatient claims (in the 
MedPAR file) from the preceding Federal fiscal year are classified 
using the DRG classification system (proposed or final) for the 
upcoming year. Cases are classified into DRGs 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. Each case is classified into one and only one DRG.
    As the term suggests, the relative weight for each DRG reflects 
relative resource use. The recalibration process requires data that 
enable us to compare resource use across DRGs. As explained earlier, as 
part of the recalibration process, we standardize the charges reflected 
on each Medicare claim to remove the effects of area wage differences, 
the IME adjustment, and the DSH adjustment; in order to standardize 
charges, we need to know which hospital furnished the service. For each 
DRG, we calculate the average of the standardized charges for the cases 
classified to the DRG. To calculate DRG relative weights, we compare 
average standardized charges across DRGs.
    In evaluating whether it is appropriate to reclassify cases from 
one DRG to another, we examine the average standardized charges for 
those cases. The recalibration process and the reclassification process 
are integrally related; to evaluate whether cases involving a certain 
procedure should be reclassified, we need to have information that (1) 
enables us to identify cases that involve the procedure and cases that 
do not involve the procedure, and (2) enables us to determine 
appropriate DRG relative weights if certain cases are reclassified.
3. Feasible, Reliable, Validated Data
    As indicated earlier, the Conference Report reflected the 
conferees' belief that, ``to the extent feasible,'' HCFA should 
consider ``reliable, validated data'' in recalibrating and 
reclassifying DRGs. The concepts of reliability and validation are 
closely related. In order for us to use non-MedPAR data, the non-MedPAR 
data must be reliable in and of itself in that the data must be 
independently validated. When an entity submits non-MedPAR data, we 
must be able to independently review the medical records and verify 
that a particular procedure was performed for each of the cases that 
purportedly involved the procedure. This verification requires the 
identification of a particular Medicare beneficiary and the hospital 
where the beneficiary was treated, as well as the dates involved. 
Although it is unlikely that we would review 100 percent of thousands 
of cases submitted for review, at a minimum, we must be able to 
validate data through a random sampling methodology. We must also be 
able to verify the charges that are reflected in the data.
    Independent validation is particularly critical in part because the 
non-MedPAR data might be submitted by (or on behalf of) entities that 
have a financial interest in obtaining a new DRG assignment and in 
obtaining the highest possible DRG relative weight. If we receive non-
MedPAR data that purport to reflect cases involving a certain procedure 
and a certain level of charges, we must have some way to verify the 
data.
    Even if non-MedPAR data are reliable and verifiable, that does not 
mean it is necessarily ``feasible'' to use the data for purposes of 
recalibration and reclassification. In order to be feasible for these 
purposes, the non-MedPAR data must enable us to appropriately measure 
relative resource use across DRGs. It is critical that cases are 
classified into one and only one DRG in the recalibration process, and 
that we have information that enables us to standardize charges for 
each case and determine appropriate DRG relative weights. Moreover, the 
data must reflect a complete set of cases or, at a minimum, a 
representative sample of hospitals and claims.
    If cases are classified into more than one DRG (or into the 
incorrect DRG) in the recalibration process, or if the non-MedPAR data 
reflect an unrepresentative sample of cases, the measure of relative 
resource would be distorted. For example, cases of percutaneous 
transluminal coronary angioplasty (PTCA) treated with GPIIb/IIIa 
platelet inhibitors (procedure code 99.20) are currently classified to 
DRG 112. The drug manufacturer has provided us with information on the 
average charges for a sample of cases that purportedly involve PTCA, 
for the purpose of evaluating whether these cases should be moved to 
the higher-weighted DRG 116. However, without adequate identification 
of the cases to allow us to specifically identify all of the cases 
treated with platelet inhibitors, the relative weight for DRG 112 would 
reflect the costs of platelet inhibitor cases. This distortion would 
result in excessive payments under DRG 112, and thus undermine the 
integrity of the recalibration process.
    Therefore, in order for the use of non-MedPAR data to be feasible, 
generally we must be able to accurately and completely identify all of 
the cases to be reclassified from one DRG to another. At a minimum, we 
must have some mechanism for ensuring that DRG weights are not 
inappropriately inflated (or deflated) to the extent that a DRG weight 
reflects cases that would be reclassified to a different DRG.
    In short, then, for use of non-MedPAR data to be feasible for 
purposes of DRG recalibration and reclassification, the data must, 
among other things (1) be independently verifiable, (2) reflect a 
complete set of cases (or a representative sample of cases), and (3) 
enable us to calculate appropriate DRG relative weights and ensure that 
cases are classified to the ``correct'' DRG, and to one DRG only, in 
the recalibration process.
    Applying this analysis, the non-MEDPAR data we have received with 
respect to platelet inhibitors are unreliable and its use is not 
feasible. The health information company, on behalf of the 
pharmaceutical company, has provided us with a sample of cases that 
purported to reflect platelet inhibitors, and also purported to reflect 
the standardized charges for those cases, but the company has failed to 
provide us with information that would enable us to verify that the 
cases actually involved platelet inhibitors or verify the level of 
charges.
    Moreover, the data are not useful for purposes of measuring 
relative resource use. We have not received sufficient information to 
verify whether the hospitals are representative of all hospitals in the 
country and whether the non-MedPAR data reflects a representative 
sample of all cases involving platelet inhibitors. Also, we have not 
received sufficient information

[[Page 24725]]

to use the non-MedPAR data to calculate appropriate DRG relative 
weights.
4. Submission of Data
    Finally, in order for use of non-MEDPAR data to be feasible, we 
must have sufficient time to evaluate and test the data. The time 
necessary to do so depends upon the nature and quality of the data 
submitted. Generally, however, a significant sample of the data should 
be submitted by August 1, approximately 8 months prior to the 
publication of the proposed rule, so that we can test the data and make 
a preliminary assessment as to the feasibility of its use. 
Subsequently, a complete database should be submitted no later than 
December 1 for consideration in conjunction with the next year's 
proposed rule.
5. How the Prospective Payment System Ensures Access to New 
Technologies
    As noted at the outset of this discussion, the Conference Report 
that accompanied the BBA indicated that we should consider non-MEDPAR 
data, to the extent feasible, ``in order to ensure that Medicare 
beneficiaries have access to innovative new drug therapies.'' (H. R. 
Conf. Rep. No. 105-217 at 734 (1997)) There seems to be a concern that, 
if a new technology is introduced, and if the new technology is costly, 
then Medicare would not make adequate payment if the new technology is 
not immediately placed in a new DRG. This concern is unfounded. As 
explained below, the Medicare hospital inpatient prospective payment 
does ensure access to new drug therapies, and new technologies in 
general.
    First, to the extent a case involving a new technology is extremely 
costly relative to the cases reflected in the DRG relative weight, the 
hospital might qualify for outlier payments, additional payments over 
and above the standard PPS payment.
    Second, Medicare promotes access to new technologies by making 
payments under the propsective payment system that are designed to 
ensure that Medicare payments for a hospital's cases as a whole are 
adequate. We establish DRGs based on factors such as clinical coherence 
and resource utilization. Each diagnosis-related group encompasses a 
variety of cases, reflecting a range of services and a range of 
resources. Generally, then, each DRG reflects some higher cost cases 
and some lower cost cases.
    For some cases, the hospital's costs might be higher than the 
payment under the propsective payment system; this does not mean that 
the DRG classifications are ``inappropriate.'' For other cases, the 
hospital's costs will be lower than the payment under the prospective 
payment system. We believe that Medicare makes appropriate payments for 
a hospital's cases as a whole.
    Each year we examine the best data available to assess whether DRG 
changes are appropriate and to recalibrate DRG relative weights. As we 
have indicated on numerous occasions, it usually takes 2 years from the 
time a procedure is assigned a code to collect the appropriate MedPAR 
data and then make an assessment as to whether a DRG change is 
appropriate. This timetable applies to reclassifications that would 
lead to decreased payment as well as those that would increase payment. 
In fact, the introduction of new technologies itself might lead to 
either higher than average costs or lower costs.
    Our ability to evaluate and implement potential DRG changes depends 
on the availability of validated, representative data. We believe that 
our policies ensure access to new technologies and are critical to the 
integrity of the recalibration process. As explained above, we remain 
open to using non-MedPAR data if the data are reliable and validated 
and enable us to appropriately measure relative resource use.

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.
    Beginning October 1, 1993, section 1886(d)(3)(E) of the Act 
requires that we update the wage index annually. 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. As discussed below in section III.F of this preamble, we also 
take into account the geographic reclassification of hospitals in 
accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when 
calculating the wage index.

B. FY 2000 Wage Index Update

    The proposed FY 2000 wage index values in section VI of the 
Addendum to this proposed rule (effective for hospital discharges 
occurring on or after October 1, 1999 and before October 1, 2000) are 
based on the data collected from the Medicare cost reports submitted by 
hospitals for cost reporting periods beginning in FY 1996 (the FY 1999 
wage index was based on FY 1995 wage data).
    We note that the FY 1999 wage index published in the July 31, 1998 
final rule was further revised on February 25, 1999 (64 FR 9378) to 
reflect approved revisions to the hospital wage data used to compute 
the wage index. In that final rule, we implemented revised wage index 
values, geographic adjustment factors, operating standardized amounts, 
and capital Federal rates for hospitals subject to the inpatient 
hospital prospective payment system. These changes are effective for 
discharges occurring on or after March 1, 1999.
    The proposed FY 2000 wage index includes the following categories 
of data associated with costs paid under the

[[Page 24726]]

hospital inpatient prospective payment system (as well as outpatient 
costs), which were also included in the FY 1999 wage index:
     Salaries and hours from short-term, acute care hospitals.
     Home office costs and hours.
     Certain contract labor costs and hours.
     Wage-related costs.
    Consistent with the wage index methodology for FY 1999, the 
proposed wage index for FY 2000 also continues to exclude the direct 
and overhead salaries and hours for services not paid through the 
inpatient prospective payment system such as skilled nursing facility 
services, home health services, or other subprovider components that 
are not subject to the prospective payment system.
    We 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. Finally, section 
4410 of the BBA 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.

C. FY 2000 Wage Index Proposals

    In the July 31, 1998 final rule, we reiterated our position that, 
to the greatest degree possible, the hospital wage index should reflect 
the wage costs associated with the areas of the hospital included under 
the hospital inpatient prospective payment system (63 FR 40970). That 
final rule contained a detailed discussion concerning the costs related 
to teaching physicians, residents, and CRNAs, all of which are paid by 
Medicare separately from the prospective payment system. For reasons 
outlined in detail in that final rule, we decided not to remove those 
costs from the calculation of the FY 1999 wage index, but to review 
updated data and consider removing them in developing the FY 2000 wage 
index.
    In response to concerns within the hospital industry related to the 
removal of these costs from the wage index calculation, the American 
Hospital Association (AHA) convened a workgroup to develop a consensus 
recommendation. The workgroup, which consisted of representatives from 
national and state hospital associations, recommended that costs 
related to teaching physicians, residents, and CRNAs should be phased 
out of the wage index calculation over a 5-year period. As discussed in 
more detail below, based upon our analysis of hospitals' FY 1996 wage 
data, and consistent with the AHA workgroup's recommendation, we are 
proposing to phase out these costs from the calculation of the wage 
index over a 5-year period. The proposed FY 2000 wage index is based on 
a blend of 80 percent of an average hourly wage including these costs, 
and 20 percent of an average hourly wage excluding these costs.
1. Teaching Physician Costs
    Before FY 1999, we included direct physician Part A costs and 
excluded contract physician Part A costs from the wage index 
calculation. Since some States prohibit hospitals from directly 
employing physicians, hospitals in these States were unable to include 
physician Part A costs because they were incurred under contract rather 
than directly. Therefore, for cost reporting periods beginning in 1995, 
we began separately collecting physician Part A costs (both direct and 
contract) so we could evaluate how to best handle these costs in the 
wage index calculation. Based on our analysis of the 1995 wage data, we 
decided to include the contract physician salaries in the wage index 
beginning with FY 1999.
    In the July 31, 1998 final rule, in response to comments regarding 
the inclusion in physician Part A costs of teaching physician costs for 
which teaching hospitals are already compensated through the Medicare 
GME payment, we stated that we would collect teaching physician data 
``as expeditiously as possible in order to analyze whether it is 
feasible to separate teaching physician costs from other physician Part 
A costs'' (63 FR 40968). Excluding teaching physician costs from the 
wage index calculation is consistent with our general policy to exclude 
from that calculation those costs that are paid separately from the 
prospective payment system.
    Because the FY 1996 cost reports did not identify teaching 
physician salaries and hours separately from physician Part A costs, we 
instructed our fiscal intermediaries to collect, through a survey, 
teaching physician costs and hours from the teaching hospitals they 
service. Specifically, we requested collection of data on the costs and 
hours related to teaching physicians that were included in Line 4 
(salaried), Line 10 (contracted), Line 12 (home office and related 
organizations), and Line 18 (wage-related costs) of the Worksheet S-3, 
Part II. In our instructions accompanying the survey, we indicated that 
these teaching-related costs are those payable under the per resident 
amounts (Sec. 413.86) and reported on Worksheet A, Line 23 of the 
hospital's cost report.
    The survey data collected as of the last week of January 1999 are 
included in the preliminary public use file made available on the 
Internet on February 5, 1999. At that time, we had received completed 
surveys for over one-half of teaching hospitals reporting physician 
Part A costs on their Worksheet S-3, Part II (372 out of 700). In early 
February 1999, we instructed intermediaries to review the survey data 
for consistency with the Supplemental Worksheet A-8-2 of the hospitals' 
cost reports. Supplemental Worksheet A-8-2 is used to apply the 
reasonable compensation equivalency limits to the costs of provider-
based physicians, itemizing these costs by the corresponding line 
number on Worksheet A.
    When we notified the fiscal intermediaries (and the fiscal 
intermediaries notified the hospitals) of the availability to review 
the survey data on the Internet, we also established deadlines of March 
5, 1999 for hospitals to request changes to the teaching survey data, 
and April 5, 1999, for the fiscal intermediaries to submit the data to 
HCRIS. The additional data collected from the hospitals through the 
fiscal intermediaries by April 5 will be included in the final wage 
data file released in May 1999.
    Due to the extraordinary effort needed to collect these data and 
the importance of accurately removing teaching physician costs, we will 
consider requests from a hospital to revise its teaching survey data as 
reflected on the final wage data file released in May 1999. (We are not 
extending the deadline for requests for revisions to cost report data.) 
Requests must be received by HCFA and the hospital's fiscal 
intermediary no later than June 7, 1999, and must include all necessary 
supporting documentation. As described above, these data were not 
originally collected on the FY 1996 cost report. The deadlines 
established under our annual process for editing and verifying the wage 
data reflect the fact that hospitals prepare and submit their cost 
reports at least 1 year, and generally more than 1 year, before the 
deadline for requesting changes. Because the timeframe in which the 
survey data were collected was considerably shorter, we have extended 
the deadline for revising those data.
    Since we published the July 31, 1998 final rule, we have received a 
recommendation from the hospital industry concerning the methodology 
that could be used to exclude physician

[[Page 24727]]

teaching-related costs from the wage index. The industry recommended 
that we implement a 5-year phase-out of all physician Part A wage costs 
that are teaching-related, as well as all resident and Part A CRNA 
costs. In FY 2000, the first year of the phase-out, the applicable wage 
index would be based on a blend of 80 percent of the current policy, 
which would include all physician Part A costs, and 20 percent of the 
new policy, which would exclude teaching physician Part A, resident, 
and CRNA costs. The percentages would be adjusted 20 percent each year 
until FY 2004, when all teaching physician, resident, and CRNA costs 
would be eliminated from the wage index calculation.
    The workgroup also recommended that if the teaching data collected 
by the intermediaries are not accurate or reliable, HCFA would include 
only 20 percent of reported physician Part A costs in the calculation, 
based on the assumption that 80 percent of total physician Part A costs 
are related to teaching physicians.
    We appreciate the industry's willingness to work with us on this 
issue and recommend a reasonable and practical solution. In developing 
our proposed FY 2000 wage index, we have adopted most of the components 
of this recommendation.
    In developing the proposed FY 2000 wage index, we calculated the 
teaching costs to be removed from the wage index as follow. If we had 
complete survey data for a hospital, that amount was subtracted from 
the amount reported on the Worksheet S-3 for physician Part A costs. 
However, relying solely on the survey data would have resulted in the 
removal of no teaching physician costs for many hospitals.
    As noted above, the hospital industry recommended that if HCFA 
believes the survey data are not reliable or accurate, it should remove 
80 percent of the total physician Part A costs and hours. Although we 
considered this option, we believe that removing 80 percent of the 
total physician Part A costs and hours across the board would not 
recognize the variations among hospitals in terms of the percentage of 
their physician Part A costs consisting of teaching physician costs. Of 
the hospitals for which we have survey data, teaching physician costs, 
as reflected on the survey, amount to, on average, approximately 68 
percent. If we adopted the recommended methodology, we would not only 
negate the efforts of those hospitals and their fiscal intermediaries 
that did complete the teaching physician survey, we would also actually 
penalize hospitals that cooperated in completing the survey by removing 
an amount in excess of actual teaching physician Part A costs they 
reported.
    Therefore, under our proposal, for any hospital that completed the 
survey, we removed from the wage data the physician Part A teaching 
costs and hours reported on the survey form. These data had been 
verified by the fiscal intermediary before submission to HCFA. If we 
did not have survey data for a teaching hospital as of February 22, 
1999, we removed 80 percent of the hospital's reported total physician 
Part A costs and hours for the proposed wage index. Based upon our 
communications with fiscal intermediaries, we believe we will have a 
substantially higher response rate for the survey data by the time we 
calculate the final FY 2000 wage index values. As discussed above, we 
have instructed the fiscal intermediaries to undertake a further 
attempt to collect these data for those hospitals that initially did 
not report survey data. We believe that since the average percentage of 
teaching costs compared to total physician Part A costs is less than 80 
percent, it would be an advantage to a hospital to complete the survey.
    Although removing 80 percent from the amount reported on the 
Worksheet S-3 for physician Part A costs allows an estimate of teaching 
physician costs to be removed in the majority of cases in which survey 
data are not available, there are instances in which a teaching 
hospital did not report either survey data or any physician Part A 
costs on its Worksheet S-3. We have identified 72 such teaching 
hospitals in our database. For purposes of calculating the proposed FY 
2000 wage index for these 72 hospitals, we subtracted the costs 
reported on Line 23 of the Worksheet A, Column 1 (Resident and Other 
Program Costs) from Line 1 of the Worksheet S-3. These costs (from Line 
23, Column 1 of Worksheet A) are included in Line 1 of the Worksheet S-
3, which is the sum of Column 1, Worksheet A. They also represent costs 
for which the hospital is paid through the per resident amount under 
the direct GME payment. Therefore, we believe it is appropriate to 
remove these costs from the wage index calculation in situations in 
which hospitals have failed to otherwise identify their teaching 
physician costs. To determine the hours to be removed, we divided the 
costs reported on Line 23 of the Worksheet A, Column 1 by the national 
average hourly wage for physician Part A costs based upon Line 4 of the 
Worksheet S-3 (the national average hourly wage is $54.48). We have 
indicated these 72 hospitals by an asterisk in Table 3C of this 
proposed rule.
    We invite comments as to whether the proposed method we have used 
to remove teaching-related costs based on the amount included in Line 
23, Column 1 of Worksheet A would be an appropriate method for removing 
GME costs in the future (and perhaps other excluded area costs as 
well). We are especially concerned that the earliest cost report on 
which we will be able to make the necessary changes to capture the 
separate reporting of teaching physician Part A costs would be cost 
reports that would be submitted for cost reporting periods beginning 
during FY 1998. Therefore, we are considering the potential for 
subtracting the costs in Lines 20, 22, and 23 of Worksheet A from Line 
1 of Worksheet S-3, Part II, in calculating the FY 2001 wage index. The 
current Worksheet S-3 is not designed to net out of Line 1 costs that 
are otherwise included in Column 1 of Worksheet A, but it would be 
possible to use data from the Worksheet A in a manner similar to that 
described above.
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 
(Sec. 412.113(c)). Because 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. 
However, because these costs were not separately identifiable before 
the FY 1995 wage data, we could not remove them.
    We began collecting the resident and CRNA wage data separately on 
the FY 1995 cost report. However, there were data reporting problems 
associated with these costs. For example, the original FY 1995 cost 
report instructions for reporting resident costs on Line 6 of Worksheet 
S-3, Part III, erroneously included teaching physician salaries and 
other teaching program costs. Also, the FY 1995 Worksheet S-3 did not 
provide for separate reporting of CRNA wage-related costs. These 
problems were corrected in the reporting instructions for the FY 1996 
cost report, and we are now proposing to remove CRNA and resident costs 
over a 5-year period.
3. Transition Period
    The proposed FY 2000 wage index is based on a blend of 80 percent 
of

[[Page 24728]]

hospitals' average hourly wages without removing the costs and hours 
associated with teaching physician Part A, residents, and CRNAs, and 20 
percent of the average hourly wage after removing these costs and hours 
from the wage index calculation. This methodology is consistent with 
the recommendation of the industry workgroup for a 5-year phase-out of 
these costs. The transition methodology is discussed in detail in 
section III.E of this preamble.

D. Verification of Wage Data From the Medicare Cost Report

    The data for the proposed FY 2000 wage index were obtained from 
Worksheet S-3, Parts II and III of the FY 1996 Medicare cost reports. 
The data file used to construct the proposed wage index includes FY 
1996 data submitted to the Health Care Provider Cost Report Information 
System (HCRIS) as of early February 1999. As in past years, we 
performed an intensive review of the wage data, mostly through the use 
of edits designed to identify aberrant data.
    From mid-January to mid-February 1999, we asked our fiscal 
intermediaries to revise or verify data elements that resulted in 
specific edit failures. Some unresolved data elements are included in 
the calculation of the proposed FY 2000 wage index pending their 
resolution before calculation of the final FY 2000 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 5, 1999. 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 removed data for eight 
hospitals that failed edits. For four 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. Two hospitals had negative average 
hourly wages after allocating overhead to their excluded areas, and 
were therefore removed from the calculation. The data from the 
remaining two hospitals were removed because inclusion of their data 
would have significantly distorted the wage index values. The data for 
these hospitals will be included in the final wage index if we receive 
corrected data that pass our edits. As a result, the proposed FY 2000 
wage index is calculated based on FY 1996 wage data for 5,035 
hospitals.

E. Computation of the Wage Index

    The method used to compute the proposed FY 2000 wage index is as 
follows:
    Step 1--As noted above, we are proposing to base the FY 2000 wage 
index on wage data reported on the FY 1996 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 II 
and III of the Medicare cost report for the hospital's cost reporting 
period beginning on or after October 1, 1995 and before October 1, 
1996. In addition, we included data from a few hospitals that had cost 
reporting periods beginning in September 1995 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 because particular labor market 
areas might be affected due to the omission of these hospitals. 
However, we generally describe these wage data as FY 1996 data.
    Step 2--Salaries--The method used to compute a hospital's average 
hourly wage is a blend of 80 percent of the hospital's average hourly 
wage including all teaching physician Part A, resident, and CRNA costs, 
and 20 percent of the hospital's average hourly wage after eliminating 
all teaching physician, resident, and CRNA costs.
    In calculating a hospital's average salaries plus wage-related 
costs, including all teaching physician Part A, resident, and CRNA 
costs, we subtracted from Line 1 (total salaries) the Part B salaries 
reported on Lines 3 and 5, home office salaries reported on Line 7, and 
excluded salaries reported on Lines 8 and 8.01 (that is, direct 
salaries attributable to skilled nursing facility services, home health 
services, and other subprovider components not subject to the 
prospective payment system). We also subtracted from Line 1 the 
salaries for which no hours were reported on Lines 2, 4, and 6. To 
determine total salaries plus wage-related costs, we added to the net 
hospital salaries the costs of contract labor for direct patient care, 
certain top management, and physician Part A services (Lines 9 and 10), 
home office salaries and wage-related costs reported by the hospital on 
Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, 
16, 18, and 20). We note that contract labor and home office salaries 
for which no corresponding hours are reported were not included.
    We then calculated a hospital's salaries plus wage-related costs by 
subtracting from total salaries the salaries plus wage-related costs 
for teaching physicians (see section III.C.1 of this preamble for a 
detail discussion of this policy), Part A CRNAs (Lines 2 and 16), and 
residents (Lines 6 and 20).
    Step 3--Hours--With the exception of wage-related costs, for which 
there are no associated hours, we computed total hours using the same 
methods as described for salaries in Step 2.
    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 (sum of 
Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours 
(Line 1 minus Lines 3, 5, and 7 of Worksheet S-3, Part II). We then 
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 13 of Worksheet S-3, Part III. 
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 adjustment, we 
estimated the percentage change in the employment cost index (ECI) for 
compensation for each 30-day increment from October 14, 1995 through 
April 15, 1997 for private industry hospital workers from the Bureau of 
Labor Statistics' Compensation and Working Conditions. We use the ECI 
because it reflects the price increase associated with total 
compensation (salaries plus fringes) rather than just the increase in 
salaries. In addition, the ECI includes managers as well as other 
hospital workers. This methodology to compute the monthly update 
factors uses actual quarterly ECI data and assures that the update 
factors match the actual quarterly and annual percent changes. The 
factors used to adjust 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
------------------------------------------------------------------------
10/14/95.........................................   11/15/95    1.023163
11/14/95.........................................   12/15/95    1.021153
12/14/95.........................................   01/15/96    1.019151
01/14/96.........................................   02/15/96    1.017157
02/14/96.........................................   03/15/96    1.015246
03/14/96.........................................   04/15/96    1.013489

[[Page 24729]]

 
04/14/96.........................................   05/15/96    1.011888
05/14/96.........................................   06/15/96    1.010428
06/14/96.........................................   07/15/96    1.009099
07/14/96.........................................   08/15/96    1.007900
08/14/96.........................................   09/15/96    1.006788
09/14/96.........................................   10/15/96    1.005719
10/14/96.........................................   11/15/96    1.004695
11/14/96.........................................   12/15/96    1.003653
12/14/96.........................................   01/15/97    1.002529
01/14/97.........................................   02/15/97    1.001325
02/14/97.........................................   03/15/97    1.000000
03/14/97.........................................   04/15/97    0.998514
------------------------------------------------------------------------

    For example, the midpoint of a cost reporting period beginning 
January 1, 1996 and ending December 31, 1996 is June 30, 1996. An 
adjustment factor of 1.009099 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 1996 and covers a period 
of less than 360 days or more 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 before 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 under both methods in Step 6 by the sum of the 
corresponding total hours (from Step 4) for all hospitals in each labor 
market area to determine an average hourly wage for the area.
    Because the proposed FY 2000 wage index is based on a blend of 
average hourly wages, we then added 80 percent of the average hourly 
wage calculated without removing teaching physician Part A, residents, 
and CRNA costs, and 20 percent of the average hourly wage calculated 
with these costs removed.
    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 same blending 
methodology described in Step 7). Using the data as described above, 
the national average hourly wage is $20.9675.
    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. (The national Puerto Rico 
standardized amount is adjusted by a wage index calculated for all 
Puerto Rico labor market areas based on the national average hourly 
wage as described above.) 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 
$9.96607 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 the BBA 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 that would have been made 
in the year if this section did not apply. For FY 2000, this change 
affects 185 hospitals in 39 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 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 in which 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

[[Page 24730]]

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 2000 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, before the redesignation of hospitals, based on the FY 1996 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 preliminary FY 1996 data as of February 22, 1999. The MGCRB will 
use the average hourly wage published in the final rule to evaluate a 
hospital's application for reclassification for FY 2001, 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. We note that in adjudicating these wage index 
reclassification requests during FY 2000, the MGCRB will use the 
average hourly wages for each hospital and labor market area that are 
reflected in the final FY 2000 wage index.
    At the time this proposed wage index was constructed, the MGCRB had 
completed its review of FY 2000 reclassification requests. The proposed 
FY 2000 wage index values incorporate all 441 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 2000. 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 following this proposed rule. The 
changes may affect not only the wage index value for specific 
geographic areas, but also the wage index value redesignated hospitals 
receive, that is, whether they 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 2000 must be received by the MGCRB by June 21, 1999. A 
hospital that requests to withdraw its application may not later 
request that the MGCRB decision be reinstated.

G. Requests for Wage Data Corrections

    To allow hospitals time to evaluate the wage data used to construct 
the proposed FY 2000 hospital wage index, we made available to the 
public a data file containing the FY 1996 hospital wage data. As stated 
in section II.D of this preamble, the data file used to construct the 
proposed wage index includes FY 1996 data submitted to HCRIS as of 
early February 1999. In a memorandum dated February 1, 1999, 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 5, 1999 through the Internet at 
HCFA's home page (http://www.hcfa.gov). We also instructed the 
intermediaries to advise hospitals of the availability of these data 
either 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. It should be noted that the hospital 
average hourly wages shown in Table 3C do not reflect any changes made 
to a hospital's data after February 22, 1999. Changes approved by a 
hospital's fiscal intermediary and forwarded to HCRIS by April 5, 1999 
will be reflected on the final public use wage data file scheduled to 
be made available May 7, 1999.
    We believe hospitals have had ample time to ensure the accuracy of 
their FY 1996 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 5, 1999, a hospital believed that its FY 1996 wage data were 
incorrectly reported, the hospital was to submit corrections along with 
complete, detailed supporting documentation to its intermediary by 
March 5, 1999. Hospitals were notified of this deadline, and of all 
other possible deadlines and requirements, through written 
communications from their fiscal intermediaries in early February 1999.
    Any wage data corrections to be reflected in the final wage index 
must have been reviewed and verified by the intermediary and 
transmitted to HCFA on or before April 5, 1999. (The deadline for 
hospitals to request changes from their fiscal intermediaries was March 
5, 1999.) These deadlines are necessary to allow sufficient time to 
review and process the data so that the final wage index calculation 
can be completed for development of the final prospective payment rates 
to be published by August 1, 1999. We cannot guarantee that corrections 
transmitted to HCFA after April 5, 1999 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 II and III to the 
hospitals. In addition, fiscal intermediaries were to notify hospitals 
of the changes or the reasons that 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

[[Page 24731]]

contact HCFA in an effort to resolve policy disputes. We note that the 
April 5 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 2000 payment rates. Accordingly, hospitals that do not 
meet the procedural deadlines set forth above will not be afforded a 
later opportunity to submit wage data corrections or to dispute the 
intermediary's decision with respect to requested changes.
    The final wage data public use file will be released by May 7, 
1999. Hospitals should examine both Table 3C of this proposed rule and 
the May 7 final public use wage data file (which reflects revisions to 
the data used to calculate the values in Table 3C) to verify the data 
HCFA is using to calculate the wage index. Hospitals will have until 
June 7, 1999 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 at that time will 
be limited to errors in the entry or tabulation of the final wage data 
that the hospital could not have known about before the release of the 
final wage data public use file.
    The final wage data file released on May 7, 1999 will contain the 
wage data that will be used to construct the wage index values in the 
final rule. As noted above in section III.C of this preamble, this file 
will include hospitals' teaching survey data as well as cost report 
data. As with the file made available in February 1999, HCFA will make 
the final wage data file released in May 1999 available to hospital 
associations and the public (on the Internet). However, with the 
exception of the teaching survey data, this file 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 5 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 7, 1999. 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; C4-07-07; 7500 Security Boulevard; 
Baltimore, MD 21244-1850. Each request must also 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 point in the process, 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. (As noted above, 
however, we are also allowing hospitals to request changes to their 
teaching survey data. These requests must comply with all of the 
documentation and deadline requirements as otherwise specified in this 
proposed rule.) 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 
5, 1999.
     Requests for correction of errors that were not, but could 
have been, identified during the hospital's review of the February 1999 
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 7, 1999) will be incorporated into the final wage index to be 
published by July 30, 1999 and effective October 1, 1999.
    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 1999, 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 2000 wage index by July 30, 1999 and the implementation of the 
FY 2000 wage index on October 1, 1999. If hospitals avail themselves of 
this opportunity, the wage index implemented on October 1 should be 
free of these 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 in which 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 2000 (that is, by the 
June 7, 1999 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.
    In the September 1, 1994 Federal Register, we stated that we did 
not believe that a ``formal appeals process'' regarding intermediary 
decisions denying hospital requests for wage data revisions was 
necessary, given the numerous opportunities provided to hospitals to 
verify and revise their data (59 FR 45351). We continue to believe that 
the process described above provides hospitals more than adequate 
opportunity to ensure that their data are correct. Nevertheless, we 
wish to clarify that, while there is no formal appeals process that 
culminates before the publication of the final rule and that is 
described above, hospitals may later seek formal review of denials of 
requests for wage data revisions made as a result of that process.
    Once the final wage index values are calculated and published in 
the Federal Register, the last opportunity for a hospital to seek to 
have its wage data revised is under the limited circumstances described 
in Sec. 412.63(w)(2). As we noted in the September 1, 1995 Federal 
Register, however, hospitals are entitled to appeal any denial of a 
request for a wage data revision made as a result of HCFA's wage data 
correction process to the Provider Reimbursement Review Board (PRRB), 
consistent with the rules for PRRB appeals found at 42 CFR part 405, 
Subpart R (60 FR 45795). As we also stated in the 1995 Federal 
Register, and as the regulation at Sec. 412.63(w)(5) provides, any 
subsequent reversal of a denial of a wage revision request that

[[Page 24732]]

results from a hospital's appeal to the PRRB or beyond will be given 
effect by paying the hospital under a revised wage index that reflects 
the revised wage data at issue. The revised wage data will not, 
however, be used for purposes of revisiting past adjudications of 
requests for geographic reclassification.

IV. Other Decisions and Proposed Changes to the Prospective Payment 
System for Inpatient Operating Costs and Graduate Medical Education 
Costs

A. Sole Community Hospitals (SCHs)(Sec. 412.92)

    If a hospital is classified as a SCH because, by reason of certain 
factors, it is the sole source of inpatient hospital services 
reasonably available to Medicare beneficiaries in a geographic area, 
the hospital is paid based on the highest of the following: the 
applicable adjusted Federal rate; the updated hospital-specific rate 
based on a 1982 base period; or the updated hospital-specific rate 
based on a 1987 base period. Under our existing rules, urban hospitals 
within 35 miles of another hospital cannot qualify as SCHs. Since 1983, 
we have consistently defined an ``urban'' area for purposes of 
determining if a hospital qualifies for SCH status as a MSA or NECMA as 
defined by OMB.
    In the past, we have considered and rejected two alternatives to 
the MSA definitions of an urban area for SCH purposes. These 
alternatives were the urbanized areas as defined by the Census Bureau 
and the health facility planning areas (HFPAs) as used by the Health 
Resource Services Administration. We have concluded that the MSA 
definition continues to be the most appropriate geographic delimiter 
available at this time. Therefore, we propose to continue to apply the 
MSA definition of an urban area for SCH status purposes.
    We propose to continue our current policy for several reasons. 
First, as we have previously noted, since OMB considers local commuting 
patterns in establishing urban definitions, we believe that residents 
in urban areas have access to hospital services either by living in 
close proximity to a hospital or by establishing a heavy commuting 
pattern to an area in which a hospital is located (48 FR 39780, 
September 1, 1983). We do not believe that either Census Bureau 
urbanized areas or HFPAs take commuting patterns into account in the 
way that OMB's MSAs do. We believe commuting patterns serve as an 
important indicia of whether a hospital is the sole hospital reasonably 
accessible by Medicare beneficiaries in an area.
    In addition, we note that our use of MSAs to define urban areas for 
SCH status purposes has direct statutory support. Section 1886(d)(2)(D) 
of the Act specifically authorizes us to use OMB's MSA definition of 
urban areas for purposes of calculating the prospective payment system 
standardized amounts. SCH status represents an adjustment to the usual 
prospective payment that a hospital would receive, and since that 
prospective payment is based on the standardized amount, among other 
factors, we believe it would be anomalous to employ one definition of 
urban area for purposes of calculating the standardized amount and 
another for purposes of determining if the hospital qualified as a SCH. 
To do so would be to use one set of geographic delimiters in applying 
the general rule (payment under the prospective payment system based on 
the standardized amount) but a different set in determining exceptions 
to the rule (payment under the prospective payment system adjusted to 
take into account SCH status). We do not think this would be 
appropriate. For this reason, also, we propose to continue to define 
``urban'' for SCH purposes as meaning MSAs as defined by OMB, not as 
meaning either Census Bureau urbanized areas or HFPAs.

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 (DSH) 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 1998 
(October 1, 1997 through September 30, 1998) and include bills posted 
to HCFA's records through December 1998. Therefore, we are proposing 
that, in addition to meeting other criteria, hospitals with fewer than 
275 beds, if they are to qualify for initial rural referral center 
status for cost reporting periods beginning on or after October 1, 
1999, must have a case-mix index value for FY 1998 that is at least--
     1.3438; or
     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 following 
table:

------------------------------------------------------------------------
                                                                Case-mix
                            Region                               index
                                                                 value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)......................     1.2480
2. Middle Atlantic (PA, NJ, NY)..............................     1.2504

[[Page 24733]]

 
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).......     1.3269
4. East North Central (IL, IN, MI, OH, WI)...................     1.2593
5. East South Central (AL, KY, MS, TN).......................     1.2772
6. West North Central (IA, KS, MN, MO, NE, ND, SD)...........     1.1871
7. West South Central (AR, LA, OK, TX).......................     1.3003
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY).................     1.3280
9. Pacific (AK, CA, HI, OR, WA)..............................     1.3277
------------------------------------------------------------------------

    The preceding numbers will be revised in the final rule to the 
extent required to reflect the updated FY 1998 MedPAR file, which will 
contain data from additional bills received through March 31, 1999.
    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 1998 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. 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 1997 (that is, October 1, 1996 through 
September 30, 1997). That is the latest year for which we have complete 
discharge data available.
    Therefore, we are proposing that, in addition to meeting other 
criteria, a hospital, if it is to qualify for initial rural referral 
center status for cost reporting periods beginning on or after October 
1, 1999, must have as the number of discharges for its cost reporting 
period that began during FY 1998 a figure that is at least--
     5,000; or
     The median number of discharges for urban hospitals in the 
census region in which the hospital is located, as indicated in the 
following table.

------------------------------------------------------------------------
                                                               Number of
                           Region                             discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).....................        6672
2. Middle Atlantic (PA, NJ, NY).............................        8635
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)......        7753
4. East North Central (IL, IN, MI, OH, WI)..................        7390
5. East South Central (AL, KY, MS, TN)......................        6741
6. West North Central (IA, KS, MN, MO, NE, ND, SD)..........        5662
7. West South Central (AR, LA, OK, TX)......................        5344
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................        7993
9. Pacific (AK, CA, HI, OR, WA).............................        5993
------------------------------------------------------------------------

    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 criterion for all hospitals. 
These numbers will be revised in the final rule based on the latest FY 
1997 cost report data.
    We reiterate that an osteopathic hospital, if it is to qualify for 
rural referral center status for cost reporting periods beginning on or 
after October 1, 1999, must have at least 3,000 discharges for its cost 
reporting period that began during FY 1997.

C. Changes to the Indirect Medical Education Adjustment (Sec. 412.105)

    Section 1886(d)(5)(B) of the Act provides that prospective payment 
hospitals that have residents in an approved graduate medical education 
(GME) program receive an additional payment to reflect the higher 
indirect operating costs associated with GME. The regulations regarding 
the calculation of this additional payment, known as the indirect 
medical education (IME) adjustment, are located at Sec. 412.105.
    In the August 29, 1997 final rule (62 FR 46029), we redesignated 
the previous Sec. 412.105(g) as Sec. 412.105(f), and added a new 
paragraph (g) to implement section 1886(d)(5)(B) of the Act as revised 
by section 4621 of the Balanced Budget Act of 1997. However, when we 
redesignated paragraph (g) as paragraph (f), we inadvertently did not 
revise all of the relevant cross-references to reflect this 
redesignation. Specifically, at Sec. 412.105(f)(1)(iii), there are 
three cross-references to paragraph (g)(1)(ii). These cross-references 
are incorrect in light of the redesignation of previous paragraph (g) 
as paragraph (f). We are proposing to revise Sec. 412.105(f)(1)(iii) to 
correct these cross-references.

D. Medicare Geographic Classification Review Board: Conforming Changes 
Secs. 412.256 and 412.276

    In the May 12, 1998 final rule (63 FR 26321), we revised the 
regulations governing the timeframes for submittal of applications by 
hospitals to the MGCRB for geographic reclassifications and for MGCRB 
decisions to take into consideration the revised statutory publication 
schedule for the annual prospective payment policies and rates (that 
is, August 1 instead of September 1) implemented by the BBA. In making 
those changes, we inadvertently omitted conforming changes to two other 
sections of the regulations that also specify timeframes that are 
affected by the change to an August 1 publication date--Secs. 412.256 
and 412.276. We propose to revise Sec. 412.256(c)(2) to specify that at 
the request of the hospital, the MGCRB may, for good cause, grant a 
hospital that has submitted an application by September 1 (instead of 
October 1) an extension beyond September 1 (instead of October 1) to 
complete its application. In addition, we propose to revise 
Sec. 412.276(a) to specify that the MGCRB notifies the parties in 
writing, with a copy to HCFA, and issues a decision within 180 days 
after the ``first day of the 13-month period preceding the Federal 
fiscal year for which the hospital had filed a completed application'' 
for reclassification, to make the language consistent with the statute 
and the May 1998 changes made to the application deadline in 
Sec. 412.256(a)(2).

E. Payment for Direct Costs of Graduate Medical Education (Sec. 413.86)

    Under section 1886(h) of the Act, Medicare pays hospitals for the 
direct costs of graduate medical education (GME). The payments are 
based on the number of residents trained by the hospital. The BBA 
revised section 1886(h) of the Act to cap the number of residents that 
hospitals may count for direct GME. We have issued rules to implement 
the caps for GME (62 FR 46002, August 29, 1997; 63 FR 26327, May 12, 
1998; and 63 FR 40986, July 31, 1998). Since the publication of these 
rules we have received a number of questions relating to GME. In 
addition, we have received information related to other aspects of our 
GME policies. In response to these questions and information, we are 
clarifying certain GME policies and also making some technical changes 
to the regulations text. In addition, we are proposing certain changes 
in GME policy.

[[Page 24734]]

1. Approved Geriatric Programs
    Under sections 1886(h)(5)(F) and (G) of the Act and Sec. 413.86(g), 
Medicare counts each resident within an initial residency period as a 
1.0 full-time equivalent (FTE) for purposes of determining GME 
payments. Each resident beyond the initial residency period is counted 
as 0.5 full-time equivalent. Section 1886(h)(5)(F) of the Act extends 
the initial residency period by up to 2 years if an individual is in a 
geriatric or preventive medicine residency or fellowship. At 
Sec. 413.86(b), we specify that an ``approved geriatric program'' is 
``a fellowship program of one or more years in length that is approved 
by the Accreditation Council for Graduate Medical Education (ACGME) 
under the ACGME's criteria for geriatric fellowship programs.'' In 
recent years, geriatric programs have been approved by other national 
organizations. Consistent with the statute, we are proposing to clarify 
the definition of approved geriatric programs at Sec. 413.86(b) to 
include fellowship programs approved by the American Osteopathic 
Association, the Commission on Dental Accreditation, and the Council on 
Podiatric Medical Education. These organizations, in addition to ACGME, 
are recognized by HCFA as the accrediting bodies for determining 
approved educational activities. We also would make a conforming change 
to Sec. 413.86(g)(1)(iii) to recognize approved geriatric programs 
accredited by all national approving organizations.
2. Hospital Payment for Resident Training in Nonhospital Settings
    Under sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act, 
hospitals may count residents working in nonhospital sites for indirect 
and direct medical education respectively if the hospital incurs ``all 
or substantially all'' of these education costs. The requirements for 
counting the time residents spend training in nonhospital settings are 
addressed at Sec. 413.86(f)(4). Currently, the requirements for 
hospital payment under this provision are that the resident spend his 
or her time in patient care activities and that a written agreement 
exist between the hospital and the nonhospital site. This written 
agreement must indicate that the hospital will incur the cost of the 
residents' salaries and fringe benefits while the residents are 
training in the nonhospital site and that the hospital is providing 
reasonable compensation to the nonhospital site for supervisory 
teaching activities. In addition, the written agreement must indicate 
the compensation the hospital is providing to the nonhospital site for 
supervisory teaching activities.
    Under the statute, the time residents spend at nonhospital sites 
may be counted ``if the hospital incurs all, or substantially all, of 
the costs of the training program in that setting.'' The existing 
regulations text, however, is framed in terms of the hospital having an 
agreement that it ``will incur'' the costs in the nonhospital setting. 
We are proposing to make a technical change to the regulations text by 
adding a new Sec. 413.86(f)(4)(iii), to clarify that in order to count 
residents at a nonhospital site, the hospital must actually incur all 
or substantially all of the costs for the training program, as defined 
in Sec. 413.86(b), in the nonhospital site. This definition of all or 
substantially all requires the hospital to incur the expenses of the 
residents' salaries and fringe benefits (including travel and lodging 
where applicable) and the portion of the cost of teaching physicians' 
salaries and fringe benefits attributable to direct GME.
3. New Residency Programs
    In the regulations we published on August 29, 1997 and May 12, 
1998, we established special rules for adjusting the full-time 
equivalent (FTE) resident caps for indirect and direct GME for new 
medical residency programs. In general, the special rules allow for 
adjustments to the caps based on a number of residents participating in 
the program in its third year of existence. In Secs. 413.86(g)(6)(i) 
and 413.86(g)(6)(ii), we set forth a methodology for adjusting hospital 
FTE caps for new medical residency training programs established on or 
after January 1, 1995. We are proposing the following clarifications, 
technical changes, and policy changes:
    a. In Sec. 413.86(g)(6)(i), we specify that, if a hospital had no 
residents before January 1, 1995, the adjustments for new programs are 
based on the highest number of residents in any program year during the 
third year of the newly established program. However, 
Sec. 413.86(g)(6)(ii) does not explicitly state the methodology for 
adjusting caps for hospitals that did have residents in the most recent 
cost reporting period ending before January 1, 1995. The adjustments of 
the caps for programs established on or after January 1, 1995 and on or 
before August 5, 1997, also are made based on the number of residents 
in the third year of the new program. We are proposing to revise 
Sec. 413.86(g)(6)(ii) to clarify that, for a hospital that did have 
residents in the most recent cost reporting period ending on or before 
December 31, 1996 (the proposed revised date described in section 
IV.E.3.d. of this preamble), the adjustment is based on the highest 
number of residents in any program year in the third year of the new 
program.
    b. Sections 413.86(g)(6)(i) and 413.86(g)(6)(ii) specify that the 
adjustment to the cap is also based on the number of years in which 
residents are expected to complete each program based on the minimum 
accredited length for the type of program. We are proposing to add 
language to clarify how to account for situations in which the 
residents spend an entire program year (or years) at one hospital and 
the remaining year (or years) of the program at another hospital. In 
this situation, the adjustment to the FTE cap is based on the number of 
years the residents are training at each hospital, not the minimum 
accredited length for the type of program. If we were to use the 
minimum accredited length for the program in this case, the total 
adjustment to the cap might exceed the total accredited slots available 
to the hospitals participating in the program. In the May 12, 1998 
final rule (63 FR 26334), we specified that the adjustment to the FTE 
cap may not exceed the number of accredited resident slots available.
    c. It was brought to our attention that the regulations do not 
explicitly address how to apply the cap during the first 3 years of a 
new program before the adjustments to the cap are established. We are 
proposing to clarify our policy on new residency programs by adding 
language in Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) to specify how 
to determine the hospital's cap in the first 3 years of a new residency 
program, before the implementation of the hospital's permanent 
adjustment to its FTE cap effective beginning with the fourth year of 
the program. We are proposing to specify that the cap may be adjusted 
during each year of the first 3 years of the hospital's new residency 
program, using the actual number of residents participating in the new 
program. The adjustment may not exceed the number of accredited slots 
available to the hospital for each program year.
    d. As discussed above, on August 29, 1997, we implemented the 
hospital-specific caps on the number of residents that a hospital can 
count for purposes of GME payments in a final rule with comment period 
(62 FR 46002). In both the May 12, 1998 and July 31, 1998 final rules 
(63 FR 26327 and 63 FR 40954), we responded to comments we received on 
this provision. We did not receive any comments about hospitals that 
participated in residency training in the

[[Page 24735]]

past, had terminated their participation prior to the hospitals' cost 
reporting period ending in calendar year 1996, and have now again begun 
a new residency program. After publication of the July 31, 1998 final 
rule, we were contacted by representatives of some hospitals that had a 
resident cap of zero because they had temporarily terminated their GME 
programs in the past and had no residents training during the cost 
reporting period ending in 1996. Based on the existing regulations, 
these hospitals have FTE caps of zero. There is no provision in the 
existing regulations for making adjustments to the cap to allow these 
hospitals to receive payment for indirect and direct GME for allopathic 
and osteopathic residents.
    To address this issue, we are proposing to revise 
Sec. 413.86(g)(6)(i) to allow for an adjustment to a hospital's FTE cap 
if the hospital had no allopathic and osteopathic residents in its cost 
reporting period ending during calendar year 1996. This change would 
allow all hospitals that did not participate in allopathic and 
osteopathic resident training in the cost reporting period ending in 
calendar year 1996 to receive adjustments to the indirect and direct 
GME FTE caps for new residency programs. We believe it is appropriate 
to revise the regulations to allow for payment during the first 3 years 
of the new program and for an adjustment to the FTE cap 3 years after 
these hospitals restart participation in residency training, similar to 
the existing adjustment for hospitals that never participated in 
residency training. We propose to revise Sec. 413.86(g)(6)(i) to allow 
a hospital that has zero residents for the cost reporting period ending 
during the calendar year 1996 to receive an adjustment. This change 
would be effective for discharges occurring on or after October 1, 
1999, for purposes of the IME adjustment and for cost reporting periods 
beginning on or after October 1, 1999, for purposes of direct GME.
    In addition, we are proposing to make a change in 
Sec. 413.86(g)(6)(ii) to make the language similar to that in 
Sec. 413.86(g)(6)(i) to specify that hospitals that did have residents 
in the cost reporting period ending on or before December 31, 1996, are 
allowed adjustments to the cap for new programs begun on or after 
January 1, 1995, and on or before August 5, 1997. Currently, 
Sec. 413.86(g)(6)(ii) refers to a hospital that did have residents in 
its most recent cost reporting period ending on or before January 1, 
1995. The regulation states that these hospitals also may qualify for 
an adjustment to the caps, but only for medical residency programs 
created on or after January 1, 1995, and on or before August 5, 1997. 
Since we are proposing to revise Sec. 413.86(g)(6)(i) to indicate that 
a hospital may qualify for an adjustment to the cap under that 
paragraph if it did not have residents in the cost reporting period 
ending during calendar year 1996, we are proposing to make a similar 
change in Sec. 413.86(g)(6)(ii) to indicate that this paragraph 
provides for an adjustment to the cap for hospitals that did have 
residents in its most recent reporting period ending on or before 
December 31, 1996. We are proposing this revision to make the language 
of these two paragraphs consistent. Hospitals may qualify either under 
Sec. 413.86(g)(6)(i) or Sec. 413.86(g)(6)(ii). For hospitals that 
qualify under Sec. 413.86(g)(6)(i), the FTE caps are established 3 
years after the hospital either begins or restarts participation in 
residency training for programs that began on or after January 1, 1995. 
However, for hospitals that qualify under Sec. 413.86(g)(6)(ii), 
adjustments to the cap are limited to those programs that began on or 
after January 1, 1995 and on or before August 5, 1997.
    e. We are proposing to make technical changes to 
Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii), which refer to whether a 
hospital had residents in its most recent cost reporting period on or 
before December 31, 1996. Instead of simply specifying ``residents,'' 
we are proposing to reference ``allopathic and osteopathic residents,'' 
because the FTE cap applies only to allopathic and osteopathy 
residents. There is no FTE cap on the number of podiatry and dentistry 
residents. Therefore, we are proposing to add the words ``allopathic 
and osteopathic'' in Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) before 
the word ``resident''.
4. Adjustment to GME Caps for Certain Hospitals To Account for 
Residents in New Medical Residency Training Programs
    Section 4623 of the BBA amended section 1886(h) of the Act to 
provide for ``special rules'' in applying FTE caps for medical 
residency training programs established on or after January 1, 1995. In 
the August 29, 1997 and May 12, 1998 final rules (62 FR 46002 and 63 FR 
26327), we implemented special rules to account for residents in new 
medical residency training programs. We are proposing to implement 
another special rule to permit an adjustment to the FTE cap for a 
hospital if the entire facility was under construction prior to August 
5, 1997 (the date of enactment of the BBA) and if the hospital 
sponsored a new medical residency training program but the residents 
temporarily trained at another hospital.
    Under current policies, if a new medical residency training was 
established on or after January 1, 1995, a hospital may receive an 
adjustment to its FTE cap to account for residents in the new program. 
If the residents in the new program begin training in one hospital and 
are subsequently ``transferred'' to another hospital, the second 
hospital does not receive an adjustment to its FTE cap; if we made an 
adjustment for the second hospital, then two hospitals would receive an 
adjustment for the same resident.
    We believe, however, that an adjustment for the second hospital 
might be appropriate in certain limited circumstances. If the second 
hospital sponsored a new medical residency training program but the 
residents in the new program temporarily trained at the first hospital 
because the second hospital was still being built, then we believe it 
might be appropriate to permit an adjustment for the second hospital. 
Otherwise, the second hospital's FTE cap would be zero, and the 
hospital would not receive any GME or IME payments.
    We are proposing to permit an adjustment under this policy only if 
the second hospital (the sponsor of the new program) began construction 
of its entire facility prior to the date of enactment of the BBA. Prior 
to August 5, 1997, a hospital would not have had knowledge of the 
provisions of the BBA and thus would not have known that a decision to 
temporarily train residents at another hospital might have resulted in 
the hospital being unable to receive GME and IME payments in the 
future. In contrast, a hospital that began construction of an entirely 
new facility on or after August 5, 1997 would have had notice of 
changes in the law prior to making a decision to temporarily train 
residents at another hospital.
    Thus, we are proposing to add a new Sec. 413.86(g)(7) (existing 
Sec. 413.86(g)(7) would be redesignated as Sec. 413.86(g)(9)) to 
address application of the FTE caps with regard to a hospital that 
began construction of an entire facility prior to August 5, 1997, 
sponsored medical residency training programs, and temporarily trained 
those residents at another hospital(s) until the new facility was 
completed. For hospitals that meet these criteria, we propose that the 
FTE caps will be determined in a manner similar to those hospitals that 
qualify for an adjustment to the FTE cap under Sec. 413.86(g)(6)(i). 
That is, the hospital's cap would equal the lesser of (a) the product 
of the highest number of

[[Page 24736]]

residents in any program year during the third year of the first 
program's existence for all new residency training programs at either 
the newly constructed facility or the temporary training site and the 
number of years in which residents are expected to complete the 
programs based on the minimum accredited length for each type of 
program; or (b) the number of accredited slots available for each year 
of the program. If the medical residency training programs sponsored by 
the newly constructed hospital have been in existence for 3 years or 
more by the time the residents begin training at the newly constructed 
hospital, the newly constructed hospital's cap would be the number of 
residents training in the third year of the first of those programs 
begun at the a temporary training site. If the medical residency 
training programs sponsored by the newly constructed hospital have been 
in existence for less than 3 years when the residents begin training at 
the newly constructed hospital, the hospital's cap would be based on 
the number of residents training at the newly constructed hospital in 
the third year of the first of those programs (including the years at 
the temporary training site). This provision would be effective for 
portions of cost reporting periods occurring on or after October 1, 
1999.
5. Temporary Adjustments to FTE Cap To Reflect Residents Affected by 
Hospital Closure
    In the May 12, 1998 prospective payment system final rule (63 FR 
26330), we indicated that we would allow a temporary adjustment to a 
hospital's resident cap under limited circumstances and if certain 
criteria are met when a hospital assumes the training of additional 
residents because of another hospital's closure. The temporary 
adjustment to the FTE cap is available to the hospital only for the 
period of time necessary to train those displaced residents. Once the 
residents leave the hospital or complete their programs, the hospital 
cap would be based solely on the statutory base year (with any 
applicable adjustments for new medical residency training programs or 
affiliated group arrangements).
    Under current policies, we permit a temporary adjustment to the FTE 
cap for a hospital only if it assumed additional medical residents from 
a hospital that closed in the July 1996-June 1997 residency training 
year. We are proposing to allow adjustments to address hospital 
closures after this period. Thus, we would allow an adjustment for a 
hospital if it takes on additional residents from a hospital that 
closes at any time on or after July 1, 1996. This adjustment is 
intended to account for residents who may have partially completed a 
medical residency training program and would be unable to complete 
their training without a residency position at another hospital.
    We are proposing this change because hospitals have indicated a 
reluctance to accept additional residents from a closed hospital 
without a temporary adjustment to their caps. Therefore, we are 
proposing to add a new Sec. 413.86(g)(8) to allow a temporary 
adjustment to a hospital's FTE cap to reflect residents added because 
of a hospital's closure at any time on or after July 1, 1996. We would 
allow an adjustment to a hospital's FTE cap if the hospital meets the 
following criteria: (a) the hospital is training additional residents 
from a hospital that closed on or after July 1, 1996; and (b) the 
hospital that is training the additional residents who are assumed from 
the closed hospital submits a request to its fiscal intermediary at 
least 60 days before the beginning of training of the residents for a 
temporary adjustment to its FTE cap, documents that the hospital is 
eligible for this temporary adjustment to its FTE cap by identifying 
the residents who have come from the closed hospital and have caused 
the hospital to exceed its cap, and specifies the length of time that 
the adjustment is needed. After the displaced residents leave the 
hospital's training program or complete their residency program, the 
hospital's cap would be based solely on the statutory base year (with 
any applicable adjustments for new medical residency training programs 
or affiliated group arrangements).
6. Determining the Weighted Number of FTE Residents
    Section 413.86(g)(1)(ii) states that for residency programs in 
osteopathy, dentistry, and podiatry, the minimum requirement for 
certification in a specialty or subspecialty is the minimum number of 
years of formal training necessary to satisfy the requirements of the 
appropriate approving body listed in Sec. 415.200(a). This reference is 
incorrect. The correct section in which approving bodies for residency 
programs are listed is Sec. 415.152. We propose to make this 
correction.
    Section 413.86(g)(1)(i) specifies that the initial residency period 
is the minimum number of years of formal training necessary to satisfy 
board eligibility in the particular specialty for which the resident is 
training, as specified in the 1985-1986 Directory of Residency Training 
Programs. Section 1886(h)(5)(G)(iii) of the Act allows the Secretary to 
increase or decrease the initial residency period if the minimum number 
of years of formal training specified in a later edition of the 
directory is different from the period specified in the 1985-1986 
Directory of Residency Training Programs. We are proposing to revise 
the regulations text to state that the initial residency period is 
determined using the most recently published edition of the Graduate 
Medical Education Directory, not the 1985-1986 Directory.
7. Clarification of a Statement in the Preamble of the May 12, 1998 
Final Rule Relating to Affiliated Groups
    In the May 12, 1998 final rule (63 FR 26341), in the third column 
of page 26341, in the sentence prior to section ``O. Payment to Managed 
Care Plans for Graduate Medical Education,'' we stated, ``If the 
combined FTE counts for the individual hospitals that are members of 
the same affiliated group do not exceed the aggregate cap, we will pay 
each hospital based on its FTE cap as adjusted per agreements.'' The 
phrase ``do not exceed'' should have read ``exceed.'' Thus, the 
sentence should have read, ``If the combined FTE counts for individual 
hospitals that are members of the same affiliated group exceed the 
aggregate cap, we will pay each hospital based on its FTE cap as 
adjusted per agreements.'' We regret any confusion that resulted from 
this misstatement.

V. Proposed Changes to the Prospective Payment System for Capital-
Related Costs: Special Exceptions Process

    Section 1886(g) of the Act requires the Secretary to pay for 
hospital capital-related costs ``in accordance with a prospective 
payment system established by the Secretary.'' Under the statute, the 
Secretary has broad authority in establishing and implementing the 
capital prospective payment system. We initially implemented the 
capital prospective payment system in an August 30, 1991 final rule (56 
FR 43409), in which we established a 10-year transition period to 
change the payment methodology for Medicare inpatient capital-related 
costs from a reasonable cost-based methodology to a prospective 
methodology (based fully on the Federal rate).
    Generally, during the transition period, inpatient capital-related 
costs will be paid on a per discharge basis, and the amount of payment 
depends on the relationship between the hospital-specific rate and the 
Federal rate during the hospital's base year. A hospital with

[[Page 24737]]

a base year hospital-specific rate less than the Federal rate will be 
paid under the fully prospective payment methodology during the 
transition period. This method is based on a dynamic blend percentage 
of the hospital's hospital-specific rate and the applicable Federal 
rate for each year during the transition period. A hospital with a base 
period hospital-specific rate greater than the Federal rate will be 
paid under the hold harmless payment methodology during the transition 
period. A hospital paid under the hold harmless payment methodology 
receives the higher of (1) a blended payment of 85 percent of 
reasonable cost for old capital plus an amount for new capital based on 
a portion of the Federal rate or (2) a payment based on 100 percent of 
the adjusted Federal rate. The amount recognized as old capital is 
generally limited to the allowable Medicare capital-related costs that 
were in use for patient care as of December 31, 1990. Under limited 
circumstances, capital-related costs for assets obligated prior to 
December 31, 1990, but put in use for patient care after December 31, 
1990 may also be recognized as old capital if certain conditions are 
met. These costs are known as obligated capital costs. New capital 
costs are generally defined as allowable Medicare capital-related costs 
for assets put in use for patient care after December 31, 1990. 
Beginning in FY 2001, at the conclusion of the transition period for 
the capital prospective payment system, capital payments will be based 
solely on the Federal rate for most hospitals.
    In the August 30, 1991 final rule, we also established a capital 
exceptions policy, which provides for exceptions payments during the 
transition period (Sec. 412.348). We also indicated that we would 
carefully monitor the impact of the capital prospective payment system 
in order to determine whether some type of permanent exceptions process 
was necessary and the circumstances under which additional payments 
would be made.
    In the Conference Report that accompanied the Omnibus Budget 
Reconciliation Act (OBRA) of 1993 (Pub. L. 103-66), Congress addressed 
obligated capital criteria for hospitals in States with a lengthy 
certificate of need (CON) process. The language states, ``The conferees 
note that in the proposed rule for fiscal year 1994 changes to the 
hospital inpatient prospective payment system that was published in the 
Federal Register on May 26, 1993, the Secretary indicated that 
insufficient information was available to complete a systematic 
evaluation of the obligated capital criteria for hospitals in states 
with a lengthy Certificate-of-Need process in time to consider 
appropriate changes during the fiscal year 1994 rulemaking process. The 
conferees expect the Secretary to complete the assessment in time for 
consideration in the fiscal year 1995 rulemaking process and that 
appropriate changes in payment policy will be made to address the 
problems of hospitals subject to a lengthy Certificate-of-Need review 
process or subject to other circumstances which are not fully addressed 
in the current rules. In addition, the conferees believe the Secretary 
should evaluate whether current policies provide adequate protection to 
sole community hospitals and hospitals that serve a disproportionate 
share of low income patients.'' (H.R. Conf. Rep. No. 103-66, at 744 
(1993)).
    In the May 27, 1994 proposed hospital inpatient prospective payment 
rule (59 FR 27744), we described our analysis of provisions related to 
obligated capital for hospitals subject to lengthy CON processes and 
proposed a change to the deadline for putting an asset into use for 
patient care (Sec. 412.302(c)(2)(i)(D)). We proposed changing the 
deadline from ``the earlier of'' September 30, 1996, or 4 years from 
the date of CON approval to ``the later of'' September 30, 1996, or 4 
years from the date of CON approval.
    In addition, in the May 27, 1994 proposed rule, we noted that the 
same hospitals that had asked for changes in the obligated capital 
provisions had also recommended changes to the capital exceptions 
policy, which would provide exceptions payments after the conclusion of 
the capital prospective payment transition period. These hospitals had 
asked that the minimum payment level for urban hospitals with at least 
100 beds and a DSH percentage of at least 20.2 percent be guaranteed 
through the rest of the transition and extended for at least 10 years 
after the transition. We noted that we had tried to address the 
concerns of these hospitals in developing the proposed special 
exceptions process that was discussed in the same proposed rule.
    In the September 1, 1994 final rule (59 FR 45376), we adopted the 
proposed change to the deadline for putting an asset into use in the 
obligated capital regulations (Sec. 412.348). We also implemented the 
capital special exceptions process and adopted qualifying criteria for 
the classes of eligible hospitals. The classes of eligible hospitals 
include urban hospitals with a DSH percentage of 20.2 percent and at 
least 100 beds and sole community hospitals.
    Under the special exceptions provision at Sec. 412.348(g), an 
additional payment may be made for up to 10 years beyond the end of the 
capital prospective payment system transition period for eligible 
hospitals that meet (1) a project need requirement, (2) a project size 
requirement, and (3) in the case of certain urban hospitals, an excess 
capacity test. In the September 1, 1994 final rule, we described the 
special exceptions process as ``* * * narrowly defined, focusing on a 
small group of hospitals who found themselves in a disadvantaged 
position. The target hospitals were those who had an immediate and 
imperative need to begin major renovations or replacements just after 
the beginning of the capital prospective payment system. These 
hospitals would not be eligible for protection under the old capital 
and obligated capital provisions, and would not have been allowed any 
time to accrue excess capital prospective payments to fund these 
projects.'' (59 FR 45385)
    In addition to sole community hospitals and urban hospitals with at 
least 100 beds that have a DSH percentage of at least 20.2 percent, 
hospitals eligible for special exceptions include urban hospitals with 
at least 100 beds that receive at least 30 percent of their revenue 
from State or local funds for indigent care, and hospitals with a 
combined inpatient Medicare and Medicaid utilization of at least 70 
percent.
    To qualify for a special exceptions payment, a hospital must 
satisfy a project need requirement as described at Sec. 412.348(g)(2) 
and a project size requirement as described at Sec. 412.348(g)(5). For 
hospitals in States with CON requirements, the project need requirement 
is satisfied by obtaining a CON approval. For other hospitals, the 
project need requirement is satisfied by meeting an age of assets test. 
The project size requirement is satisfied if the hospital completes the 
qualifying project between the period beginning on or after its first 
cost reporting period beginning on or after October 1, 1991, and the 
end of its last cost reporting period beginning before October 1, 2001, 
and the project costs are (1) at least $200 million or (2) at least 100 
percent of the hospital's operating cost during the first 12-month cost 
reporting period beginning on or after October 1, 1991. The minimum 
payment level under special exceptions for all qualifying hospitals is 
70 percent of allowable capital-related costs. Special exception 
payments are offset against positive Medicare capital and operating 
margins.

[[Page 24738]]

    When we established the special exceptions process, we selected the 
hospital's cost reporting period beginning before October 1, 2001, as 
the project completion date in order to limit cost-based exceptions 
payments to a period of not more than 10 years beyond the end of the 
transition to the fully Federal capital prospective payment system. 
Because hospitals are eligible to receive special exceptions payments 
for up to 10 years from the year in which they complete their project 
(but for not more than 10 years after September 30, 2001, the end of 
the capital prospective payment transition), if a project is completed 
by September 30, 2001, exceptions payments could continue up to 
September 30, 2011. In addition, we believed that for projects 
completed after the September 30, 2001, hospitals would have had the 
opportunity to reserve their prior years' capital prospective payment 
system payments for financing projects.
    In the July 31, 1998 final rule (63 FR 40999), we stated that a few 
hospitals had expressed concern with the required completion date of 
October 1, 2001, and other qualifying criteria for the special 
exceptions payment. Therefore, we solicited certain information from 
hospitals on major capital construction projects that might qualify for 
the capital special exceptions payments so we could determine if any 
changes in the special exceptions criteria or process were necessary.
    Four hospitals responded timely with information on their major 
capital construction projects. The hospitals submitted information 
about their location, the cost of the project, the date that the 
certificate of need approval was received, the start date of the 
project, and the anticipated completion date.
    Some hospitals suggested that we change the existing project 
completion date criterion, that is, the criterion that the qualifying 
projects must be completed between the hospital's first cost reporting 
period beginning on or after October 1, 1991, and the end of its last 
cost reporting period beginning before October 1, 2001. They proposed 
that, as an alternative, a hospital be eligible for the special 
exceptions payment if the hospital had received its CON approval for 
the qualifying project by September 1, 1995, and had spent $750,000 or 
10 percent of total project cost by that date, and that the project 
completion date be changed to December 31, 2005 (which would be well 
beyond the 10 years we have established for the capital prospective 
payment system transition). However, other hospitals recommended that 
we not institute a date by which a hospital must have received its CON 
approval.
    In addition, some hospitals have suggested other ways in which the 
special exceptions process could be revised. Some of these hospitals 
expressed concern about the project size requirement and stated that 
small community-based institutions were unlikely to be able to support 
debt in the range of $200 million.
    We understand that a few hospitals may not meet the DSH percentage 
requirement of at least 20.2 percent. Some of these hospitals suggested 
lowering the qualifying percentage to 15 percent. They also suggested 
changing the payment level for special exceptions from 70 percent to 85 
percent and changing the requirement at Sec. 412.348(g)(8)(ii)(B) that 
special exception payments be offset against positive Medicare 
operating and capital margins. They suggested limiting the offset 
provision to capital margins. In addition, some of these hospitals 
suggested capping special exceptions payments that result from changes 
to the current special exceptions process at $40 million annually.
    While we have no specific proposal at this time to revise the 
special exceptions process, we specifically invite comments from 
hospitals and other interested parties on the suggestions and 
recommendations discussed above. We note that, since the capital 
special exceptions process is budget neutral, any liberalization of the 
policy would require a commensurate reduction in the capital rate paid 
to all hospitals. Even after the end of the capital prospective payment 
system transition, we will continue to make an adjustment to the 
capital Federal rate in a budget neutral manner to pay for exceptions, 
as long as an exceptions policy is in force. Currently, the limited 
special exceptions policy will allow for exceptions payments through 
September 30, 2011.
    We have little information about the impact of any of the 
recommended changes, since no hospitals are currently being paid under 
the special exceptions process. Until FY 2001, the special exceptions 
provision pays either the same as the regular exceptions process or 
less for high DSH and sole community hospitals. We will attempt to 
obtain information on projects that may qualify for special exceptions 
payments through our fiscal intermediaries during the comment period. 
However, we are reluctant to place a significant data gathering burden 
on fiscal intermediaries at this time because of their current workload 
resulting from the major efforts to make the Medicare computer systems 
compliant on January 1, 2000. Based on comments that we receive from 
hospitals and any data received from the fiscal intermediaries, we may 
address changes to the special exceptions criteria in the final rule, 
or we may propose changes in the criteria in the FY 2001 hospital 
inpatient prospective payment system proposed rule.

VI. Proposed Changes for Hospitals and Hospital Units Excluded From 
the Prospective Payment System

A. Limits on and Adjustments to the Target Amounts for Excluded 
Hospitals and Units (Secs. 413.40(b)(4) and (g))

1. Updated Caps
    Section 1886(b)(3) of the Act (as amended by section 4414 of the 
BBA) establishes caps on the target amounts for certain 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); the May 12, 1998 final rule (63 FR 26344); and the July 31, 
1998 final rule (64 FR 41000). For purposes of calculating the caps, 
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 current estimate of the market basket increase for excluded 
hospitals and units for FY 2000 is 2.6 percent. Accordingly, the 
proposed caps on target amounts for cost reporting periods beginning in 
FY 2000 are as follows:

 Psychiatric hospitals and units: $11,067
 Rehabilitation hospitals and units: $20,071
 Long-term care hospitals: $39,596
2. New Excluded Hospitals and Units (Sec. 413.40(f))
    a. Updated Caps for New Hospitals and Units. Section 1886(b)(7) of 
the Act establishes a payment methodology for new psychiatric hospitals 
and units, rehabilitation hospitals and units, and long-term care 
hospitals. Under the statutory methodology, for a hospital that is 
within a class of hospitals specified in the statute and that first

[[Page 24739]]

receives payments as a hospital or unit excluded from the prospective 
payment system on or after October 1, 1997, the amount of payment will 
be determined as follows. For the first two 12-month cost reporting 
periods, the amount of payment is the lesser of (1) the operating costs 
per case, or (2) 110 percent of the national median of target amounts 
for the same class of hospitals for cost reporting periods ending 
during FY 1996, updated to the first cost reporting period in which the 
hospital receives payments and adjusted for differences in area wage 
levels.
    The proposed amounts included in the following table reflect the 
updated 110 percent of the wage neutral national median target amounts 
for each class of excluded hospitals and units for cost reporting 
periods beginning during FY 2000. These figures are updates to the 
final FY 1999 figures by the estimated market basket increase of 2.6 
percent. For a new provider, the labor-related share of the target 
amount is multiplied by the appropriate geographic area wage index and 
added to the nonlabor-related share in order to determine the per case 
limit on payment under the statutory payment methodology for new 
providers.

------------------------------------------------------------------------
                                                      Labor-   Nonlabor-
        Class of excluded hospital or unit           related    related
                                                      share      share
------------------------------------------------------------------------
Psychiatric.......................................     $6,376     $2,536
Rehabilitation....................................     12,537      4,984
Long-Term Care....................................     16,158      6,424
------------------------------------------------------------------------

    b. Multicampus Excluded Hospitals. Section 1886(b) of the Act, as 
amended by the BBA, provides for caps on target amounts for certain 
classes of excluded hospitals, and also provides a statutory payment 
methodology for new excluded hospitals. A question has arisen regarding 
the appropriate target amount to be used for an excluded hospital or 
unit that was part of a multicampus hospital but alters its 
organizational structure so that it is no longer part of that 
multicampus hospital. The question was raised by long-term care 
hospitals that are seeking alternate structures due to the application 
of the cap on hospital-specific target amounts specified in 
Sec. 413.40(c)(4)(iii).
    In these cases, to determine the appropriate target amount, we must 
determine whether the excluded hospital or unit established under the 
organizational restructure is a new provider. Under Sec. 413.40(f)(1), 
a new excluded hospital or unit is a provider of hospital inpatient 
services that (1) has operated as the type of hospital or unit for 
which HCFA granted it approval to participate in the Medicare program, 
under present or previous ownership (or both), for less than 1 full 
year; and (2) has provided the type of hospital inpatient services for 
which HCFA granted it approval to participate for less than 2 full 
years. For a new children's hospital, a 2-year exemption from the 
application of the target amount is permitted (Sec. 413.40(f)(2)(i)). 
For the first two 12-month cost reporting periods, a new psychiatric or 
rehabilitation hospital or unit or a long-term care hospital receives 
the lower of its new inpatient operating cost per case or 110 percent 
of a national median of target amounts for the class of hospital, 
updated and adjusted for area wages (Sec. 413.40(f)(2)(ii)).
    If the entity that separated itself from the multicampus hospital 
provides inpatient services of a different type than it had when it was 
part of the multicampus hospital so that it qualifies as a different 
class of excluded hospital or unit (for example, from long-term care to 
rehabilitation), we would calculate a new target amount per discharge 
for the newly created hospital or unit. However, if the entity does not 
operate as a different class of hospital or unit, it does not meet the 
criteria at Sec. 413.40(f)(1) to qualify as a new provider. Instead, if 
the entity replaces a hospital or unit that had been excluded from the 
prospective payment system (for example, the entity had previously been 
a long-term care hospital before becoming part of the multicampus 
hospital), the previously established hospital-specific target amount 
for the hospital prior to becoming part of the multicampus hospital 
would again be applicable. This is consistent with our current policy 
for a hospital or unit excluded from the prospective payment system 
that has periods in which the hospital or unit is not subject to the 
target amount, as specified at Sec. 413.40(b)(1)(i). The target amount 
established earlier for the hospital or unit is again applicable 
despite intervening cost reporting periods during which the hospital or 
unit was not subject to that target amount due to other provisions of 
the law or regulations that applied while it was part of the 
multicampus hospital. In contrast, we propose to revise 
Sec. 413.40(b)(1)(iii) to specify that if the entity continues to 
operate as the same class of hospital that is excluded from the 
prospective payment system, but does not replace a provider that 
existed prior to being part of a multicampus hospital (for example, a 
newly created long-term care hospital became part of a multicampus 
hospital and subsequently separates from the multicampus hospital to 
operate separately), the base period for calculating a hospital-
specific target amount for the newly separated hospital is the first 
cost reporting period of at least 12 months effective with the revised 
Medicare certification.
3. Exceptions
    The August 29, 1997 final rule with comment period (62 FR 46018) 
specified that a hospital that has a hospital-specific target amount 
that is capped at the 75th percentile of target amounts for hospitals 
in the same class (psychiatric, rehabilitation, or long-term care) 
would not be granted an adjustment payment (also referred to as an 
exception payment) 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.
    In addition, the July 31, 1998 final rule (63 FR 41001) revised 
Sec. 413.40(g)(1) to specify, under paragraph (g)(1)(iv), that in the 
case of a psychiatric hospital or unit, rehabilitation hospital or 
unit, or long-term care hospital, the amount of the adjustment payment 
may not exceed the applicable limit amounts for hospitals of the same 
class.
    Similarly, for hospitals and units with a FY 1998 hospital-specific 
revised target amount established under the rebasing provision at 
Sec. 413.40(b)(1)(iv), in determining whether the hospital qualifies 
for an adjustment and the amount of the adjustment, we compare the 
hospital's operating costs to the average costs and statistics for the 
cost reporting periods used to determine the FY 1998 revised target 
amount. Since the rebased FY 1998 target amount is an average of three 
cost reporting periods, as described in Sec. 413.40(b)(1)(iv), 
comparisons of costs from the cost year to the FY 1998 cost period 
would be inaccurate. Therefore, as specified in the August 29, 1997 
final rule with comment period (62 FR 46018), a determination of 
whether the hospital qualifies for an adjustment and the amount of an 
adjustment is based on a comparison of the hospital's operating costs 
and its costs used to calculate the FY 1998 rebased target amount.
    The conditions that must be met to qualify for an adjustment remain 
unchanged, as specified in Chapter 30 of the Provider Reimbursement 
Manual. Making comparisons between the base year and the cost year 
requires that each particular inpatient service be

[[Page 24740]]

compared. For example, to determine whether the hospital qualifies for 
an adjustment and the amount of an adjustment for increased routine 
services or an increase in a particular ancillary service, we compare 
the costs incurred by the hospital in the cost year to the hospital's 
routine services or ancillary services in the base year. Therefore, for 
hospitals that have been rebased under the provisions of 
Sec. 413.40(b)(1)(iv) and qualify for an adjustment under the 
provisions of Sec. 413.40(g), the base year figures used for costs, 
utilization, length-of-stay, etc., are determined based on the average 
of the costs and utilization statistics from the same 3 cost reporting 
years used in calculating the FY 1998 rebased target amount. While we 
recognize that additional calculations are necessary to prepare an 
adjustment payment request in this manner, we believe it is the most 
equitable means of determining an adjustment payment. We also point out 
that the averaging calculation for the various cost centers and 
utilization statistics must only be performed the first year a provider 
requests an adjustment after FY 1998, and thereafter those averaged 
calculations may be utilized for subsequent years' adjustment requests.
    Therefore, once these averages are calculated, the same values will 
be used for determining the amount of any subsequent year adjustments.
    We propose to revise Sec. 413.40(g)(1) to clarify these limitations 
on the adjustment payments.
4. Development of Case-Mix Adjusted Prospective Payment System for 
Rehabilitation Hospitals and Units
    Section 4421 of the BBA added a new section 1886(j) to the Act 
which mandates the phase-in of a case-mix adjusted prospective payment 
system for inpatient rehabilitation services (freestanding hospitals 
and units) for cost reporting periods beginning on or after October 1, 
2000 and before October 1, 2002. The prospective payment system will be 
fully implemented for cost reporting periods beginning on or after 
October 1, 2002.
    As provided in section 1886(j)(3)(A) of the Act, the prospective 
payment rates will be based on the inpatient operating and capital 
costs of rehabilitation facilities. Payments will be adjusted for case-
mix using patient classification groups, area wages, inflation, and 
outlier and any other factors the Secretary determines necessary. We 
will set prospective payment amounts so that total payments under the 
system during FY 2001 and FY 2002 are projected to equal 98 percent of 
the amount of payments that would have been made under the current 
payment system. Outlier payments in a fiscal year may not be projected 
or estimated to exceed 5 percent of the total payments based on the 
rates for that fiscal year.

B. Changes in Bed Size or Status of Hospital Units Excluded Under the 
Prospective Payment System

    Existing regulations (Secs. 412.25(b) and (c)) specify that, for 
purposes of payment to a psychiatric or rehabilitation unit that is 
excluded from the prospective payment system, changes in the bed size 
or the status of excluded hospital units will be recognized only at the 
beginning of a cost reporting period. These regulations have been in 
effect since the inception of the inpatient hospital prospective 
payment system and were intended to simplify administration of the 
exclusion provisions of the prospective payment systems by establishing 
clear rules for the timing of changes in these excluded units.
    Recently, a number of hospitals have suggested that we consider a 
change in our policy to recognize, for purposes of exclusion from the 
prospective payment system, reductions in number of beds in, or entire 
closure of, units at any time during a cost reporting period. They 
indicated that the bed capacity made available as a result of these 
changes could be used, as they need them, to provide additional 
services to meet patient needs in the acute care part of the hospital 
that is paid under the prospective payment system.
    We have evaluated the concerns of the hospitals and the effect on 
the administration of the Medicare program and the health care of 
beneficiaries of making these payment changes. As a result of this 
evaluation, we believe it is reasonable to adopt a more flexible policy 
on recognition of hospitals' changes in the use of their facilities. 
However, we note that whenever a hospital establishes an excluded unit 
within the hospital, our Medicare fiscal intermediary must be able to 
determine costs of the unit separately from costs of the part of the 
hospital paid under the prospective payment system. The proper 
determination of costs ensures that the hospital is paid the correct 
amount for services in each part of the facility, and that payments 
under the prospective payment system do not duplicate payments made 
under the rules applicable to excluded hospitals and units, or vice 
versa. For this reason, we do not believe it would be appropriate to 
recognize, for purposes of exclusion from the prospective payment 
system, changes in the bed size or status of an excluded unit that are 
so frequent that they interfere with the ability of the intermediary to 
accurately determine costs.
    Moreover, section 1886(d)(1)(B) of the Act authorizes exclusion 
from the prospective payment system of specific types of hospitals and 
units, but not of specific admissions or stays, such as admissions for 
rehabilitation or psychiatric care, in a hospital paid under the 
prospective payment system. Without limits on the frequency of changes 
in excluded units for purposes of proper Medicare payment, there is the 
potential for some hospitals to adjust the status or size of their 
excluded units so frequently that the units would no longer be distinct 
entities and the exclusion would effectively apply only to certain 
types of care.
    To provide more flexibility to hospitals while not recognizing 
changes that undermine statutory requirements and principles, we 
propose to revise Secs. 412.25(b) and (c) to provide that, for purposes 
of exclusion from the prospective payment system, the number of beds 
and square footage of an excluded unit may be decreased, or an excluded 
unit may be closed in its entirety, at any time during a cost reporting 
period under certain conditions. The hospital would be required to give 
the fiscal intermediary and the HCFA Regional Office a 30-day advance 
written notice of the intended change and to maintain all information 
needed to accurately determine costs attributable to the excluded unit 
and proper payments. However, any unit that is closed during a cost 
reporting period could not be paid again as a unit excluded from the 
prospective payment system until the start of the next cost reporting 
period. If the number of beds or square footage of a unit excluded from 
the prospective payment system is decreased during a cost reporting 
period, that decrease would remain in effect for the remainder of that 
period.
    We note that the number of beds and square footage of the part of 
the hospital paid under the prospective payment system may also be 
affected by a change in the size or status of a unit that is excluded 
from the prospective payment system. If the bed capacity and square 
footage were previously part of the excluded unit and are then included 
in the part of the hospital paid under the prospective payment system 
and are used to treat acute patients rather than excluded unit 
patients, the additional bed capacity and square footage would, 
starting with the effective date of the change, be counted as part of 
the

[[Page 24741]]

hospital paid under the prospective payment system. We would count the 
bed capacity and square footage for purposes of calculating available 
bed-days and the number of beds under Secs. 412.105 and 412.106, 
relating to payments for the indirect costs of GME and service to a 
disproportionate share of low-income patients. On the other hand, if 
the bed capacity and square footage are taken out of service or added 
to another Medicare provider, such as a distinct-part SNF, they would 
not be counted as part of the hospital paid under the prospective 
payment system.

C. Payment for Services Furnished at Satellite Hospital Locations

    Under Medicare, each hospital is treated, for purposes of 
certification, coverage, and payment, as a single institution. That is, 
each entity that is approved to participate in Medicare as a 
``hospital'' must separately comply with applicable health and safety 
requirements as a condition of participation under regulations at Part 
482, with provider agreement requirements specified in regulations at 
Part 489, and with requirements relating to the scope of benefits under 
Medicare Part A and B specified in parts 409 and 410. Our policies that 
involve the movement of patients from one hospital to another, or from 
outpatient to inpatient status at a same hospital, are premised on the 
assumption that each hospital is organized and operated as a separate 
institution.
    Section 412.22(e) of the regulations permits an entity that is 
located in the same building or in separate buildings on the same 
campus as another hospital to be treated, for purposes of exclusion 
under the prospective payment systems, as a ``hospital within a 
hospital.'' This status is available, however, only when the entity 
meets specific, stringent criteria designed to ensure that the 
hospital-within-a-hospital is organized as a separate entity and 
operates as a separate entity.
    Recently, we have received several requests for approval of 
``satellite'' arrangements, under which an existing hospital that is 
excluded under the prospective payment system, and that is either a 
freestanding hospital or a hospital-within-a-hospital under 
Sec. 412.22(e), wishes to lease space in a building or on a campus 
occupied by another hospital, and, in some cases, to have most or all 
services to patients furnished by the other hospital under contractual 
agreements, including arrangements permitted under section 1861(w)(1) 
of the Act. In most cases, a hospital intends to have several of these 
satellite locations so that the hospital would not exist at any single 
location, but only as an aggregation of beds located at several sites. 
Generally, the excluded hospital seeks to have the satellite facility 
treated as if the satellite facility were ``part of'' the excluded 
hospital.
    The fundamental problem with satellite arrangements is that the 
satellite facility might be ``part of'' the excluded hospital only on a 
nominal basis (that is, only on paper). The satellite facility might 
not operate as part of the excluded hospital, but instead might 
effectively be a ``part of'' the hospital within which it is located, 
or might effectively be its own separate entity. From a payment 
perspective, if the satellite facility is effectively not part of the 
excluded hospital, then Medicare would make inappropriately high 
payments if Medicare treats the satellite facility as part of the 
excluded hospital.
    Perhaps most significantly, if Medicare treated the satellite 
facility as part of the excluded hospital, the services in the 
satellite facility might inappropriately be paid by Medicare on the 
basis of reasonable costs (subject to limits) when they should be paid 
on the basis of prospective payment. If the satellite facility operates 
as ``part of'' the prospective payment system hospital in which it is 
located, and not as part of the excluded hospital with which it is 
affiliated, then the considerations underlying exclusion from the 
prospective payment system do not apply to the services furnished in 
satellite facilities. Thus, if the satellite facility is effectively 
part of the prospective payment system hospital, then the services 
should be paid under the prospective payment system.
    Satellite arrangements can lead to inappropriate Medicare payments 
in a number of ways. For example, an excluded long-term care hospital 
might set up a satellite facility within an acute care hospital paid 
under the prospective payment system. Such a configuration could make 
it relatively easy for the prospective payment hospital to discharge a 
patient prematurely to the excluded long-term care hospital satellite 
location that is in its building or on its campus. The result could be 
inappropriate duplication of payment, in that the prospective payment 
system hospital would receive full payment under the DRG system even if 
it did not complete the acute treatment of the patient, and the 
hospital excluded under the prospective payment systems would receive 
payment for some services that should have been furnished in the 
prospective payment system hospital and paid under the prospective 
payment system. While the discharge and transfer regulations at 
Sec. 412.4 provide disincentives to these inappropriate transfers in 
some 10 DRGs, there are many other cases not assigned to these DRGs in 
which such transfers could occur.
    Another potential abuse related to duplication of Medicare payment 
could occur with respect to the preadmission payment window provisions 
of section 1886(a)(4) of the Act (implemented under regulations at 
Secs. 412.2(c)(5) and 413.40(c)(2)). Under the regulations, services 
provided by the hospital or by an entity wholly owned or operated by 
the hospital within the 3 calendar days before admission to a 
prospective payment system hospital, or within 1 calendar day before 
admission to a hospital excluded from the prospective payment system, 
are treated for payment purposes as if they had been furnished during 
the inpatient stay. For prospective payment system hospitals, the 
provision is designed to prevent services historically furnished by 
hospitals during the early parts of inpatient stays from being 
``unbundled'' and furnished just prior to admission and billed on an 
outpatient basis. If this situation were to occur, the result would be 
that outpatient payment under Medicare Part B would be made for 
services for which Part A payment is provided under the prospective 
payment system, that is, duplication of payments for outpatient and 
inpatient services. For hospitals excluded from the prospective payment 
system, the payment window provision is intended to minimize 
beneficiary liability for Part B deductible and coinsurance amounts 
while encouraging use of outpatient facilities rather than inpatient 
facilities when appropriate.
    If excluded hospitals were able to set up satellite facilities 
within hospitals paid under the prospective payment system and obtain 
exclusion from the prospective payment system for the satellite 
facilities, the two hospitals could easily circumvent the preadmission 
payment window requirements by setting up outpatient departments of 
both hospitals at each site where both have inpatient facilities, and 
scheduling patients who are to be admitted to one hospital to receive 
preadmission care at the outpatient department of the other hospital. 
Thus, exclusion of satellite facilities could result in payments that 
are inconsistent with the purpose of the payment window. (We note that 
this abuse could also occur, at least theoretically, if the satellite 
facilities were not excluded from the prospective payment system. 
However, allowing exclusion from the

[[Page 24742]]

prospective payment system of satellites increases the likelihood that 
such arrangements will actually be set up.)
    There also is a potential for satellite facilities to be used as a 
means to avoid the effects of section 4416 of the BBA, which is 
implemented in regulations at Sec. 413.40(f)(2)(ii). This section 
limits the target amounts for psychiatric and rehabilitation hospitals 
and units and long-term care hospitals that are first paid as hospitals 
excluded from the prospective payment system on or after October 1, 
1997, to 110 percent of the national median of the target amounts of 
similarly classified hospitals. This limitation applies to the 
hospital's first two 12-month cost reporting periods. Section 
413.40(c)(4)(iii), which implements provisions of section 4414 of the 
BBA, sets the 75th percentile of the target amounts of similarly 
classified hospitals as a limit on costs for psychiatric and 
rehabilitation hospitals and units and long-term care hospitals 
excluded from the prospective payment system before October 1, 1997. If 
we permitted exclusion of satellite facilities, a hospital chain could 
set up new locations and avoid the limits applicable to new providers 
by characterizing the new locations as satellites of existing 
hospitals. This result would effectively nullify the anticipated 
budgetary savings of section 4416 of the BBA in such situations.
    While many hospitals furnish care to cancer patients, exclusion 
from the prospective payment system as a cancer hospital is not 
available to a facility unless it was classified as such on or before 
December 31, 1991 (section 1886(d)(10)(B)(v) of the act and regulations 
at Sec. 412.23(f)). The statute effectively prohibits recognition of 
newly established hospitals as cancer hospitals. If we were to permit 
satellite locations of excluded hospitals to be set up within 
prospective payment system hospitals and to be excluded from the 
prospective payment system, existing cancer hospitals might set up 
satellite locations in prospective payment hospitals, thus avoiding the 
prohibition on new cancer hospitals. This practice would be 
inconsistent with section 1886(d)(10)(B)(v) and its implementing 
regulations. It also could potentially allow a hospital under the 
prospective payment system to admit or transfer all high-cost cancer 
patients to the ``cancer hospital satellite'' while making a profit on 
the low-cost cancer patients remaining at the prospective payment 
system hospital.
    Finally, we note that rehabilitation units that are excluded from 
the prospective payment system are required to have a medical director 
of rehabilitation who furnishes services to the unit or its patients at 
least 20 hours per week (Sec. 412.29(f)(1)). However, this requirement 
presumably would not apply if the facility is described not as a unit 
of the hospital in which it is based, but as a satellite of an existing 
rehabilitation hospital, since that hospital would already have its 
medical director. The existence of a high level of physician oversight 
of rehabilitation is a key identifier of the kind of unit that provides 
inpatient hospital-level rehabilitation care as its primary activity, 
not merely as an adjunct or extension of acute care. We believe 
allowing satellites of rehabilitation hospitals to be set up in 
prospective payment system hospitals and excluded from the prospective 
payment system would undermine the requirement for that level of 
physician oversight, and limit our ability to exclude only those units 
providing the appropriate level of rehabilitation services.
    We believe that a number of excluded hospitals are seeking 
satellite arrangements so that the services furnished in the satellite 
facility are inappropriately paid on an excluded basis when they should 
be paid on a prospective basis. We also believe that a number of 
excluded hospitals are seeking satellite arrangements in order to avoid 
the effect of the payment caps that apply to new hospitals and would 
apply to the satellite facility if the satellite facility received 
separate certification. And, as discussed above, satellite arrangements 
can lead to other problems. To prevent inappropriate Medicare payment 
for services furnished in satellite facilities, we propose to revise 
Secs. 412.22 and 412.25 to provide for payment to satellite facilities 
of hospitals and units that are excluded from the prospective payment 
system under specific rules. With respect to both hospitals and units, 
we would define ``satellite facility'' as a part of a hospital that 
provides inpatient services in a building also used by another 
hospital, or in one or more buildings on the same campus as buildings 
also used by another hospital, but is not a ``hospital-within-a-
hospital,'' since it is also part of another hospital. If the satellite 
facility is located in a hospital that is paid under the prospective 
payment system, Medicare would pay for services furnished at the 
satellite facility by using the same rates that apply to the 
prospective payment hospital within which the satellite is located. As 
explained earlier, we believe that, if the satellite facility is 
effectively ``part of'' the prospective payment system hospital, then 
it should be paid under the prospective payment system.
    If the satellite facility is located in a hospital excluded from 
the prospective payment system, then Medicare would pay for the 
services furnished in the satellite facility as follows: we would 
examine the discharges of the satellite facility and we would apply the 
target amount for the excluded hospital in which the hospital is 
located, subject to the applicable cap for the hospital of which the 
satellite is a part. Also, when the satellite facility is established, 
we would treat the satellite facility as a new hospital for payment 
purposes. That is, for the satellite's first two 12-month cost 
reporting periods, the satellite would be subject to the cap that 
applies to new hospitals of the same class as the hospital of which the 
satellite is a part. We believe that application of the cap for new 
hospitals is appropriate because we believe that a number of hospitals 
are attempting to avoid the new hospital caps by characterizing 
entities as satellites rather than new hospitals.
    Under our proposal, satellite facilities excluded from the 
prospective payment system prior to the effective date of the revised 
regulations (October 1, 1999) would not be subject to those new 
regulations as long as they operate under the same terms and conditions 
in effect on September 30, 1999. We would make this exception available 
only to those facilities that can document to the HCFA regional offices 
that they are operating as satellite facilities excluded from the 
prospective payment system as of that date, not to facilities that 
might be excluded from the prospective payment system as of that date 
and at some later time enter into satellite arrangements. The proposed 
rules for payments to satellite facilities would not apply to 
multicampus arrangements, that is, those in which a hospital has 
several locations but does not share a building or a campus with any 
other hospital at any location.
    We also solicit comment on a possible further exception. In section 
4417 of the BBA, Congress extended the long-term care hospital 
exclusion to a hospital ``that first received payment under this 
subsection [subsection 1886(d)(1)(B)(iv) of the Act] in 1986 which has 
an average inpatient length of stay (as determined by the Secretary) of 
greater than 20 days and that has 80 percent or more of its annual 
Medicare inpatient discharges with a principal diagnosis of neoplastic 
disease in the 12-month cost reporting period ending in fiscal year 
1997.'' In view of the specific provision made for a hospital meeting 
these requirements, we are considering whether a satellite facility 
opened by such a hospital

[[Page 24743]]

should be exempt from the proposed rules on satellites on this 
preamble. We welcome comment on this issue and on whether such an 
exclusion could be implemented without compromising the effectiveness 
of the proposed changes.
    We recognize that there may be some operational difficulties 
differentiating services, costs, and discharges of the satellite 
facilities from those of the existing hospital that is excluded from 
the prospective payment system. If these operational problems cannot be 
overcome, we might, in the final rule, revise Secs. 412.22 and 412.25 
to prohibit exclusion of any hospital or hospital unit from the 
prospective payment system that is structured, entirely or in part, as 
a satellite facility in a hospital paid under the prospective payment 
system. The effect of this change would be that all Medicare payments 
to such a hospital or hospital unit with a satellite facility would be 
made under the prospective payment system.
    Before deciding to propose these changes, we considered whether the 
hospital-within-a-hospital rules in Sec. 412.22(e) provide adequate 
protection against abuses of the prospective payment system exclusion 
by satellite facilities. For the reasons described below, we concluded 
that they do not.
    The current hospital-within-a-hospital criteria were issued through 
proposed rules published in the Federal Register on May 27, 1994 (59 FR 
27708) and final rules published on September 1, 1994 (59 FR 45330). In 
those documents, we explained that the DRG system is based on an 
averaging concept that provides appropriate payment for the type and 
mix of cases treated by acute care hospitals, but that the averaging 
concept underlying the DRG system does not apply to long-stay 
hospitals, which have few short-stay or low-cost cases and might be 
systematically underpaid if the prospective payment system were applied 
to them. We explained that it would not be appropriate to make 
prospective payment system exclusion available to long-stay units of 
acute hospitals, since those units account for only part of the 
hospital's patient load and the principles underlying the prospective 
payment system do apply to the larger hospital. We also stated that the 
hospital-within-a-hospital criteria, now codified at Sec. 412.22(e), 
ensure that facilities structured as hospitals-within-hospitals are 
sufficiently separate from the host hospitals to warrant exclusion from 
the prospective payment system as separate hospitals.
    The considerations that make it inappropriate to exclude long-stay 
units of general hospitals from the prospective payment system also 
make it inappropriate, in our view, to allow exclusion from prospective 
payment system of facilities that treat only a part of the patient load 
of the larger prospective payment system hospitals in which they are 
located, but are presented as satellites of another facility. In 
responding to a comment in the September 1, 1994 final rule, we stated 
that we believe that the hospital-within-a-hospital criteria should 
have application in all cases involving joint occupancy of a building 
or campus by an applicant long-term hospital and another hospital (59 
FR 45330). After further review of the issue, however, we have now 
concluded that while the hospital-within-a-hospital criteria are 
designed to prevent potential abuses similar to those posed by 
satellites, the criteria themselves cannot be effectively applied to 
satellite arrangements. This is because the criteria are designed to 
apply to hospitals that exist only in one location. For example, under 
Sec. 412.22(e)(5)(ii), one criterion for showing separate operation of 
a hospital-within-a-hospital is that the hospital's costs of services 
obtained under contracts or other arrangements from the host hospital 
(or from a controlling third entity) be no more than 15 percent of the 
hospital's total inpatient operating cost. Because a satellite facility 
would integrate its costs with those of the hospital with which it is 
affiliated, it is possible that the entire hospital could meet this 
test even though all costs of the satellite facility were incurred 
under contracts or arrangements. Likewise, the criterion regarding the 
source of inpatient referrals (Sec. 412.22(e)(5)(iii)) could be met by 
an entire hospital, even though most or all patients treated at a 
satellite facility were referred from the hospital in which the 
satellite is located. Thus, existing hospital-within-a-hospital 
criteria are not adequate to deal with satellite issues.

D. Responsibility for Care of Patients in Hospitals Within Hospitals

    Normally, hospitals that admit patients, including hospitals 
subject to the prospective payment system and ``hospitals-within-
hospitals'' that are excluded from the prospective payment system, 
accept overall responsibility for the patients' care and furnish all 
services they require. In accordance with section 1886(d)(5)(I) of the 
Act and implementing regulations at Sec. 412.4, for payment purposes, 
the prospective payment system distinguishes between ``discharges'' 
(situations in which a patient leaves an acute care hospital paid under 
the prospective payment system after receiving complete acute care 
treatment) and ``transfers'' (situations in which acute care treatment 
is not completed at the first hospital and the patient is transferred 
to another acute care hospital for continued, related care). The 
payment rules at Sec. 413.30, which apply to hospitals excluded from 
the prospective payment system, also are premised on the assumption 
that discharges occur only when the excluded hospital's care of the 
patient is complete.
    It has come to our attention that, given the co-location of 
prospective payment system facilities and facilities excluded from the 
prospective payment system in a hospital-within-a-hospital, and the 
absence of clinical constraints on the movement of patients, there may 
be situations where, in such settings, patients appear to have been 
moved from one facility to another for financial rather than clinical 
reasons. The excluded hospital-within-a-hospital might have incentives 
to inappropriately discharge patients early (to the prospective payment 
system hospital within which it is located) in order to minimize its 
overall costs and in turn to minimize its cost per discharge. If the 
excluded hospital-within-a-hospital inappropriately discharges patients 
to the prospective payment system hospital without providing a complete 
episode of the type of care furnished by the excluded hospital, then 
Medicare would make inappropriate payments to the hospital-within-a-
hospital. This is the case because payments made to an excluded 
hospital are made on a per-stay basis, up to the hospital's per 
discharge target amount, and any artificial decrease in the hospital's 
cost per stay could lead to the hospital inappropriately avoiding its 
target amount cap mandated by section 4414 of the BBA and receiving 
inappropriate bonus and relief payments under section 4415 of the BBA.
    For example, if a long-term care hospital has an average length of 
stay of 30 days and incurs a cost per patient-day of $1,500, its 
average cost per stay is $45,000 ($1,500  x  30). If that hospital 
discharged 20 percent of its patients to a prospective payment system 
hospital before the 30th day of their stay at the long-term care 
hospital, the patients might still stay, on average, a total of 30 days 
at the two hospitals. However, by transferring an increased number of 
patients early during the period, the long-term care hospital would be 
able to reduce its cost per discharge.
    If the hospital's cap on its target amount is $38,593 and the 
hospital's cost per discharge is $45,000, then the hospital's payments 
would be based on

[[Page 24744]]

a target amount of $38,593. If, as a result of the inappropriate 
discharges, the cost per stay is $37,500, Medicare payment to the 
hospital would be based on a target amount of $37,500, plus an 
additional amount under the bonus provisions of Sec. 413.40(d)(2). In 
addition, a separate DRG payment would be made to the prospective 
payment system hospital that completed the treatment at the satellite 
location. Thus, Medicare payments for a 30-day period of inpatient care 
would increase without any additional quality of care or benefit to the 
patient. The additional payment would merely be a result of 
artificially decreasing the long-term care hospital's cost per 
discharge and adding a second payment to the prospective payment system 
hospital.
    We believe it is important to address possible financial incentives 
for inappropriate early discharges from excluded hospitals-within-
hospitals to prospective payment system hospitals. Therefore, we 
considered several approaches for preventing inappropriate Medicare 
payments to an excluded hospital-within-a-hospital for inappropriate 
discharges to the prospective payment system hospital in which it is 
located. One approach would be to provide that, if an excluded 
hospital-within-a-hospital transfers patients from its beds to beds of 
the prospective payment system hospital with which it is located, the 
hospital-within-a-hospital would not qualify for exclusion in the next 
cost reporting period. We recognize that this approach might 
``penalize'' hospitals for transfers that are medically appropriate. 
However, we need to balance (1) our concern with preventing 
inappropriate Medicare payment and (2) our need to have a rule that is 
administratively feasible.
    A second possible approach would be to provide that the hospital-
within-a-hospital would qualify for exclusion only if it transfers 
patients to the prospective payment system hospital only when the 
services the patients require cannot be furnished by the hospital-
within-a-hospital. This approach has the advantage of specifically 
targeting inappropriate early discharges, but it has the significant 
disadvantage of being difficult if not impossible to administer because 
of the extent of case review that would be required to implement it.
    After considering these options, we have decided to propose a third 
approach. Under this approach, we would deny exclusion to a hospital-
within-a-hospital for a cost reporting period if, during the most 
recent cost reporting period for which information is available, the 
excluded hospital-within-a-hospital transferred more than 5 percent of 
its inpatients to the prospective payment system hospital in which it 
is located. We believe that a 5-percent allowance of transfers under 
this approach would (1) avoid the need for administratively burdensome 
case review, (2) provide adequate flexibility for transfers in those 
cases where the hospital-within-a-hospital is not equipped or staffed 
to provide the services required by the patient, and (3) limit the 
extent to which patients may be transferred inappropriately.
    We welcome comments on our proposed approach as well as suggestions 
on other ways to address the possible incentives for inappropriate 
transfers in a manner that is administratively feasible.

E. Critical Access Hospitals (CAHS)

1. Emergency Response Time Requirements for CAHs in Frontier and Remote 
Areas
    Because of the high cost of staffing rural hospital emergency rooms 
and the low volume of services in those facilities, we do not require 
CAHs to have emergency personnel on site at all times. Thus, for CAHs, 
the regulations at Sec. 485.618(d) require a doctor of medicine or a 
doctor of osteopathy, a physician assistant, or a nurse practitioner 
with training and experience in emergency care to be on call and 
immediately available by telephone or radio contact, and available on 
site within 30 minutes, on a 24-hour basis. We included this 
requirement because we recognize the need of rural residents to have 
reasonable access to emergency care in their local communities.
    Section 1820(h) of the Act, as added by section 4201 of the BBA, 
states that any medical assistance facility (MAF) in Montana shall be 
deemed to have been certified by the Secretary as a CAH if that 
facility is otherwise eligible to be designated by the State as a CAH. 
However, under the current requirements, following the initial 
transition of a MAF to CAH status, the former MAF would be subject to 
the CAH requirements during any subsequent review, one of which is the 
30-minute emergency response time for emergency services currently 
required under Sec. 485.518(d).
    Recently, some facilities have suggested that in many ``frontier'' 
areas (that is, those having fewer than six residents per square mile), 
the requirement of a 30-minute response might be too restrictive for 
CAHs, especially those MAFs transitioning to CAH status.
    We are aware it is costly and difficult to recruit and train the 
personnel needed to operate emergency rooms in the most remote, 
sparsely populated rural areas. On the other hand, in contemplating any 
changes to the emergency response timeframe for CAHs, we must ensure 
that the response time is not extended to the point that patient health 
and safety are jeopardized.
    In order to recognize the special needs of sparsely populated rural 
areas in meeting beneficiaries' health needs, and at the same time to 
protect patients' health and safety, we are proposing to revise 
Sec. 485.618(d) to allow a response time of up to 60 minutes for a CAH 
if (1) it is located in an area of the State that is defined as a 
frontier area (that is, having fewer than six residents per square mile 
based on the latest population data published by the Bureau of the 
Census) or meets other criteria for a remote location adopted by the 
State and approved by HCFA under criteria specified in its rural health 
care plan under section 1820(b) of the Act; (2) the State determines 
that, under its rural health care plan, allowing the longer emergency 
response time is the only feasible method of providing emergency care 
to residents of the area; and (3) the State maintains documentation 
showing that a response time up to 60 minutes at a particular CAH it 
designates is justified because other available alternatives would 
increase the time required to stabilize the patient in an emergency. 
The criteria for remote location would, like other parts of the rural 
health care plan, be subject to review and approval by the HCFA 
Regional Office, as would the State's documentation regarding the 
emergency response time.
    We note that, under the terms of the Montana State Code applicable 
to MAFs, at times when no emergency response person is available to 
come to the facility, a MAF's director of nursing is permitted to come 
to the facility and authorize the transfer of a patient seeking 
emergency services to another facility. Under one possible reading of 
the State requirement, this activity could be seen as an alternative 
way of complying with the emergency services requirement and the MAF's 
(and CAH's) responsibilities under section 1867 of the Act (the 
Emergency Medical Treatment and Active Labor Amendments Provision) to 
provide emergency medical screening and stabilization services to 
patients who come to the hospital seeking emergency treatment. We 
request comments on

[[Page 24745]]

whether the Medicare regulations in Secs. 485.618(d) and 489.24 should 
be further revised to explicitly permit this practice to continue 
following the transition of a MAF to CAH status. We are particularly 
interested in obtaining comment from practitioners on the risks and 
benefits involved in adoption of this practice.
2. Compliance With Minimum Data Set (MDS) Requirements by CAHs With 
Swing-Bed Approval
    Existing regulations allow CAHs to obtain approval from HCFA to use 
their inpatient beds to provide posthospital SNF care (Sec. 485.645). 
To obtain such approval, however, the CAH must agree to meet specific 
requirements that also apply to SNFs, including the comprehensive 
assessment requirements at Sec. 483.20(b) of the SNF conditions of 
participation.
    Section 483.20(b)(1) specifies that a SNF must make a comprehensive 
assessment of a resident's needs, using the resident assessment 
instrument specified by the State. Section 483.20(b)(2) further 
specifies that, subject to the timeframes in Sec. 413.343(b), the 
assessments must be conducted within 14 calendar days after the patient 
is admitted; within 14 days after the facility determines, or should 
have determined, that there is a significant change in the patient's 
physical or mental condition; and at least once every 12 months. 
Section 413.343(b) specifies that in accordance with the methodology in 
Sec. 413.337(c) related to the adjustment of the Federal rates for 
case-mix (the SNF prospective payment system), patient assessments must 
be performed on the 5th, 14th, 30th, 60th, and 90th days following 
admission.
    It is clear that the timeframes for patient assessments required 
under Sec. 413.343(b) are linked to the prospective payment system for 
SNFs. The methodology specifically referenced in Sec. 413.337(c) refers 
to the SNF prospective payment system. Therefore, it is apparent that 
the patient assessments and concomitant timeframes for performing such 
assessments are inextricably intertwined with the case-mix adjustment 
under the SNF prospective payment system. CAHs with swing-bed approval 
are not paid for their services to SNF-level patients under that SNF 
prospective payment system but are paid under the payment method 
described in Sec. 413.114, which does not include a case-mix 
adjustment. Therefore, the timeframes for patient assessments as 
dictated by Sec. 413.343(b) are not applicable to CAHs and are not 
required to be met by CAHs. Nevertheless, to make it explicit that the 
patient assessment timeframes required under Sec. 413.343(b) do not 
apply, we propose to revise Sec. 485.645 to state that the requirements 
in Sec. 413.343(b), and the timeframes specified in Sec. 483.20, do not 
apply to CAHs.

VII. MedPAC Recommendations

    We have reviewed the March 1, 1999 report submitted by MedPAC to 
Congress and have given its recommendations careful consideration in 
conjunction with the proposals set forth in this document. 
Recommendations 3A and 3B concerning the update factors for inpatient 
hospital 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. Other recommendations are discussed 
below.

A. Excluded Hospitals and Hospital Units (Recommendations 4B and 4C)

    Recommendation: The Congress should adjust the wage-related portion 
of the excluded hospital target amount caps (the 75th percentile of 
target amounts for hospitals in the same class (psychiatric hospital or 
unit, rehabilitation hospital or unit, or long-term care hospitals)) to 
account for geographic differences in labor costs. The Commission 
presumes legislation would be necessary to adjust the caps for wages.
    Response: We previously addressed this issue in the May 12, 1998 
final rule (63 FR 26345). In that discussion, we explain why we believe 
the statutory language, the statutory scheme, and the legislative 
history, viewed together, strongly argue against making a wage 
adjustment in applying the target amount caps under the current 
statute.
    Recommendation: Additional research in case-mix classification 
systems for psychiatric patients should be encouraged, with the aim of 
developing a case-mix adjusted prospective payment system for 
psychiatric patients in the future.
    Response: As MedPAC indicated in its recommendation discussion, 
prior research has indicated substantial difficulties in developing a 
psychiatric case-mix classification system. Another issue is the 
adequate identification of a system that reflects the unique 
characteristics of psychiatric care for the Medicare population, 
primarily the elderly. During the past year, we have met with industry 
representatives to discuss further research efforts on this issue as 
well as understand the initial impacts of the recent legislative 
changes to excluded hospital payment system on psychiatric hospitals 
and units. We will continue these efforts in FY 2000.

B. Disproportionate Share Hospitals (DSH) (Recommendations 3C, 3D, and 
3E)

    Recommendations: The Congress should require that disproportionate 
share payments be distributed according to each hospital's share of 
low-income patient costs, defined broadly to include all care to the 
poor. The measure of low-income costs should reflect: (1) Medicare 
patients eligible for Supplemental Security Income, Medicaid patients, 
patients sponsored by other indigent care programs, and uninsured and 
underinsured patients as represented by uncompensated care (both 
charity and bad debts); and (2) services provided in both inpatient and 
outpatient settings.
    As under current policy, disproportionate share payment should be 
made in the form of an adjustment to the per-case payment rate. In this 
way, the total payment each hospital receives will reflect its volume 
of Medicare patients.
    Through a minimum threshold for low-income share, the formula for 
distributing disproportionate share payments should concentrate 
payments among hospitals with the highest shares of poor patients. A 
reasonable range for this threshold would be levels that make between 
50 percent and 60 percent of hospitals eligible for a payment. The size 
of the payment adjustment, however, should increase gradually from zero 
at the threshold. The same distribution formula should apply to all 
hospitals covered by prospective payment.
    The Secretary should collect the data necessary to revise the 
disproportionate share payment system from all hospitals paid under 
prospective payment system.
    Response: We continue to give careful consideration to MedPAC's 
recommendations concerning the DSH adjustment made to operating 
payments under the prospective payment system.
    We are in the process of preparing a report to Congress on the 
Medicare DSH adjustment that includes several options for amending the 
statutory disproportionate share adjustment formula. We believe that 
any adjustment to the DSH formula or data sources should be directed 
and supported by the Congress.
    The MedPAC option involves collecting data on uncompensated care, 
that is, charity and bad debts. Ideally, this would be a direct measure 
of a hospital's indigent care burden. However, there are problems 
associated with verification of such data and

[[Page 24746]]

consistency of reporting nationally. We appreciate the Commission's 
recommendations about and assistance with the Medicare DSH adjustment 
as we formulate our legislative proposal and await Congressional 
action.

VIII. 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. This file, scheduled to be available by the end of 
April, 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. The FY 1998 
MedPAR file used for the FY 2000 final rule will be cutoff 6 months 
after the end of the fiscal year (March file) and is scheduled to be 
available by the end of April.

Media: Tape/Cartridge
File Cost: $3,655.00 per fiscal year
Periods Available: FY 1988 through FY 1998
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. This file, 
scheduled to be available by the end of April, 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. The FY 1998 
MedPAR file used for the FY 2000 final rule will be cutoff 6 months 
after the end of the fiscal year (March file) and is scheduled to be 
available by the end of April.

Media: Tape/Cartridge
File Cost: $1,130.00 per State per year
Periods Available: FY 1988 through FY 1998
3. HCFA Wage Data
    This file contains the hospital hours and salaries for 1996 used to 
create the proposed FY 2000 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.

------------------------------------------------------------------------
                                                 Wage data    PPS fiscal
                Processing year                     year         year
------------------------------------------------------------------------
1999..........................................         1996         2000
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.
     Final Rule published in the Federal Register.

Media: Diskette/most recent year on the Internet
File Cost: $165.00 per year
Periods Available: FY 2000 PPS Update
4. HCFA Hospital Wages Indices (Formerly: Urban and Rural Wage Index 
Values Only)
    This file contains a history of all wage indices since October 1, 
1983.

Media: Diskette/most recent year on the Internet
File Cost: $165.00 per year
Periods Available: FY 2000 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
File Cost: $165.00 per year
Periods Available: FY 2000 PPS Update
6. Reclassified Hospitals New Wage Index (Formerly: Reclassified 
Hospitals by Provider Only)
    This file contains a list of hospitals that were reclassified for 
the purpose of assigning a new wage index. Two versions of these files 
are created each year. They support the following:
     NPRM published in the Federal Register.
     Final Rule published in the Federal Register.

Media: Diskette/Internet
File Cost: $165.00 per year
Periods Available: FY 2000 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,

[[Page 24747]]

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 and PPS-XIV Minimum Data Sets are part of the 
PPS-XIII and PPS-XIV Hospital Data Set Files.)

File Cost: $770.00 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 and PPS-XIV Capital Data Sets are part of the 
PPS-XIII and PPS-XIV Hospital Data Set Files.)

File Cost: $770.00 per year
9. PPS-XIII and PPS-XIV Hospital Data Set
    The file contains cost, statistical, financial, and other data from 
the Medicare Hospital Cost Report. The data set includes only the most 
current cost (as submitted, final settled, or reopened) submitted for a 
Medicare Certified Hospital by the Medicare Fiscal Intermediary to 
HCFA. The data set are updated at the end of each calendar quarter and 
is available on the last day of the following month.

Media: Diskette/Internet
File Cost: $2,500.00

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-XIII......................................     10/01/95     10/01/96
PPS-XIV.......................................     10/01/96     10/01/97
------------------------------------------------------------------------

10. 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 2000 PPS Update
11. 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.
     Final rule published in the Federal Register.

Media: Diskette/most recent year on Internet
Price: $165.00 per year/per file
Periods Available: FY 1985 through FY 1998
12. 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:
     NPRM.
     Final rule.

Media: Diskette/Internet
File Cost: $165.00
Periods Available: FY 2000 PPS Update
13. 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: $165.00
Periods Available: FY 2000 PPS Update
14. 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.
     Final rule published in the Federal Register.

Media: Diskette/Internet
File Cost: $165.00
Periods Available: FY 2000 PPS Update

    For further information concerning these data tapes, contact The 
HCFA Public Use Files Hotline at (410) 786-3691.
    Commenters interested in obtaining or discussing any other data 
used in constructing this rule should contact Stephen Phillips at (410) 
786-4531.

B. Public Comments

    Because of the large number of items of correspondence we normally 
receive on a proposed rule, we are not able to acknowledge or respond 
to them individually. However, in preparing the final rule, we will 
consider all comments concerning the provisions of this proposed rule 
that we receive by the date and time specified in the DATES section of 
this preamble and respond to those comments in the preamble to that 
rule. We emphasize that, given the statutory requirement under section 
1886(e)(5) of the Act that our final rule for FY 2000 be published by 
August 1, 1999, we will consider only those

[[Page 24748]]

comments that deal specifically with the matters discussed in this 
proposed rule.

List of Subjects

42 CFR Part 412

    Administrative practice and procedure, Health facilities, Medicare, 
Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

    Health facilities, Kidney diseases, Medicare, Puerto Rico, 
Reporting and recordkeeping requirements.

42 CFR Part 483

    Grant programs-health, Health facilities, Health professions, 
Health records, Medicaid, Medicare, Nursing homes, Nutrition, Reporting 
and recordkeeping requirements, Safety.

42 CFR Part 485

    Grant programs-health, Health facilities, Medicaid, Medicare, 
Reporting and recordkeeping requirements.

    42 CFR Chapter IV is amended as set forth below:

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    A. Part 412 is amended as follows:
    1. The authority citation for Part 412 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. Section 412.22 is amended by adding new paragraphs (e)(6) and 
(h) to read as follows:


Sec. 412.22  Excluded hospitals and hospital units: General rules.

* * * * *
    (e) Hospitals-within-hospitals. * * *
    (6) Responsibility for care of patients. During the most recent 
cost reporting period for which information is available, the hospital 
transferred no more than 5 percent of its inpatients to the prospective 
payment system hospital within which it is located.
* * * * *
    (h) Satellite facilities. (1) For purposes of paragraphs (h)(2) 
through (h)(5) of this section, a satellite facility is a part of a 
hospital that provides inpatient services in a building also used by 
another hospital, or in one or more entire buildings located on the 
same campus as buildings used by another hospital.
    (2) Effective for cost reporting periods beginning on or after 
October 1, 1999, payment for services furnished in satellite facilities 
of hospitals excluded from the prospective payment systems is made in 
accordance with the rules specified in paragraphs (h)(3) and (h)(4) of 
this section.
    (3) If the satellite facility occupies space in the same building 
or on the same campus as a hospital paid under the prospective payment 
system, payment for services furnished at the satellite facility is 
based on the same rates that apply to the prospective payment system 
hospital within which the satellite is located.
    (4) If the satellite facility occupies space in the same building 
or on the same campus as a hospital excluded from the prospective 
payment systems, payment for services furnished at the satellite 
facility is made as follows:
    (i) For the first two 12-month cost reporting periods during which 
the satellite facility treats patients, payment for services furnished 
at the satellite facility is made in accordance with the provisions of 
Sec. 413.40(f)(2) of this subchapter.
    (ii) For subsequent cost reporting periods, payment for services 
furnished at the satellite facility is made based on the target amount 
of the excluded hospital in which the satellite is located, but is 
subject to the cap at the hospital of which the satellite is a part.
    (5) The provisions of paragraphs (h)(2) through (h)(4) of this 
section do not apply to any hospital or entity structured as a 
satellite facility on September 30, 1999, and excluded from the 
prospective payment systems on that date, to the extent the hospital 
continues operating under the same terms and conditions, including the 
number of beds and square footage considered, for purposes of Medicare 
participation and payment, to be part of the hospital, in effect on 
September 30, 1999.
    3. Section 412.25 is amended by revising paragraphs (b) and (c) and 
adding a new paragraph (e) to read as follows:


Sec. 412.25  Excluded hospital units: common requirements.

* * * * *
    (b) Changes in the size of excluded units. For purposes of 
exclusions from the prospective payment systems under this section, 
changes in the number of beds and square footage considered to be part 
of each excluded unit are allowed as specified in paragraphs (b)(1) and 
(b)(2) of this section.
    (1) Increase in size. The number of beds and square footage of an 
excluded unit may be increased only at the start of a cost reporting 
period.
    (2) Decrease in size. The number of beds and square footage of an 
excluded unit may be decreased at any time during a cost reporting 
period if the hospital notifies the fiscal intermediary and the HCFA 
Regional Office in writing of the planned decrease at least 30 days 
before the date of the decrease, and maintains the information needed 
to accurately determine costs that are attributable to the excluded 
unit. Any decrease in the number of beds or square footage considered 
to be part of an excluded unit made during a cost reporting period 
continues in effect for the remainder of that period.
    (c) Changes in the status of hospital units. For purposes of 
exclusions from the prospective payment systems under this section, the 
status of each hospital unit (excluded or not excluded) is determined 
as specified in paragraphs (c)(1) and (c)(2) of this section.
    (1) The status of a hospital unit may be changed from not excluded 
to excluded only at the start of a cost reporting period. If a unit is 
added to a hospital after the start of a cost reporting period, it 
cannot be excluded from the prospective payment systems before the 
start of a hospital's next cost reporting period.
    (2) The status of a hospital unit may be changed from excluded to 
not excluded at any time during a cost reporting period, but only if 
the hospital notifies the fiscal intermediary and the HCFA Regional 
Office in writing of the change at least 30 days before the date of the 
change, and maintains the information needed to accurately determine 
costs that are or are not attributable to the excluded unit. A change 
in the status of a unit from excluded to not excluded that is made 
during a cost reporting period continues in effect for the remainder of 
that period.
* * * * *
    (e) Satellite facilities. (1) For purposes of paragraphs (e)(2) 
through (e)(5) of this section, a satellite facility is a part of a 
hospital that provides inpatient services in a building also used by 
another hospital, or in one or more entire buildings located on the 
same campus as buildings used by another hospital.
    (2) Effective for cost reporting periods beginning on or after 
October 1, 1999, payment for services furnished in psychiatric or 
rehabilitation units that are structured, entirely or in part, as 
satellite facilities are made in accordance with the rules specified in 
paragraphs (e)(3) and (e)(4) of this section.
    (3) If the satellite facility occupies space in the same building 
or on the same campus as a hospital paid under the prospective payment 
systems,

[[Page 24749]]

payment for services furnished at the satellite facility is based on 
same rates that apply to the prospective payment system hospital within 
which the satellite is located.
    (4) If the satellite facility occupies space in the same building 
or on the same campus as a hospital excluded from the prospective 
payment systems, payment for services furnished at the satellite 
facility is made as follows:
    (i) For the first two 12-month cost reporting periods during which 
the satellite facility treats patients, payment for services furnished 
at the satellite facility is made in accordance with the provisions of 
Sec. 413.40(f)(2) of this subchapter.
    (ii) For subsequent cost reporting periods, payment for services 
furnished at the satellite facility is made based on the target amount 
of the excluded hospital in which the satellite is located, but is 
subject to the cap of the hospital of which the satellite is a part.
    (5) The provisions of paragraph (e)(2) through (e)(4) of this 
section do not apply to any unit structured as a satellite facility on 
September 30, 1999, and excluded from the prospective payment systems 
on that date, to the extent the unit continues operating under the same 
terms and conditions, including the number of beds and square footage 
considered to be part of the unit, in effect on September 30, 1999.


Sec. 412.105  [Amended]

    4. Section 412.105 is amended by revising the cross reference 
``paragraph (g)(1)(ii) of this section'' in paragraphs (f)(1)(iii) 
(three times) and (f)(2)(v) to read ``paragraph (f)(1)(ii) of this 
section''.


Sec. 412.256  [Amended]

    5. In Sec. 412.256, paragraph (c)(2), the date ``October 1'', 
appearing in two places, is revised to read ``September 1''.
    6. Section 412.276 is amended by revising paragraph (a) to read as 
follows:


Sec. 412.276  Timing of MGCRB decision and its appeal.

    (a) Timing. The MGCRB notifies the parties in writing, with a copy 
to HCFA, and issues a decision within 180 days after the first day of 
the 13-month period preceding the Federal fiscal year for which a 
hospital has filed a complete application. The hospital has 15 days 
from the date of the decision to request Administrator review.
* * * * *

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED 
PAYMENT RATES FOR SKILLED NURSING FACILITIES

    B. Part 413 is amended as follows:

    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), 1871, 1881, 1883, and 1886 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).

    2. Section 413.40 is amended by revising paragraphs (b)(1)(iii) and 
(g)(1) to read as follows:


Sec. 413.40  Ceiling on the rate-of-increase in hospital inpatient 
costs.

* * * * *
    (b) Cost reporting periods subject to the rate-of-increase ceiling. 
(1) Base period. * * *
    (iii) When the operational structure of a hospital or unit changes 
(that is, a freestanding hospital becomes a unit or vice versa, or an 
entity of a multicampus hospital becomes a newly created hospital or 
unit or vice versa), the base period for the hospital or unit that 
changed its operational structure is the first cost reporting period of 
at least 12 months effective with the revised Medicare certification 
classification.
* * * * *
    (g) Adjustment. (1) General rules. (i) 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 in paragraphs (g)(2), (g)(3), and (g)(4) of 
this section.
    (ii) 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.
    (iii) When an adjustment is requested by the hospital, HCFA makes 
an adjustment only if the hospital's operating costs exceed the rate-
of-increase ceiling imposed under this section.
    (iv) In the case of a psychiatric hospital or unit, rehabilitation 
hospital or unit, or long-term care hospital, the amount of payment 
under paragraph (g)(3) of this section may not exceed the payment 
amount based on the target amount determined under paragraph 
(c)(4)(iii) of this section.
    (v) In the case of a hospital or unit that received a revised FY 
1998 target amount under the rebasing provisions of paragraph 
(b)(1)(iv) of this section, the amount of an adjustment payment for a 
cost reporting period is based on a comparison of the hospital's 
operating costs for the cost reporting period to the average costs and 
statistics for the cost reporting periods used to determine the FY 1998 
rebased target amount.
* * * * *


Sec. 413.86  [Amended]

    3. Section 413.86 is amended as follows:
    a. In paragraph (b), the definition of ``approved geriatric 
program'' is revised to read: ``Approved geriatric program means a 
fellowship program of one or more years in length that is approved by 
one of the national organizations listed in Sec. 415.152 of this 
chapter under that respective organization's criteria for geriatric 
fellowship programs.''
    b. In paragraph (b), under paragraph (1) of the definition of 
``approved medical residency program'', the reference ``Sec. 415.200(a) 
of this chapter'' is revised to read ``Sec. 415.152 of this chapter''.
    c. In paragraph (e)(1)(ii)(C), the reference ``paragraph (j)(2) of 
this section'' is revised to read ``paragraph (k)(1) of this section''.
    d. In paragraph (e)(1)(iv), the reference, ``paragraph (j)(1) of 
this section'', is revised to read ``paragraph (k)(1) of this 
section''.
    e. A new paragraph (f)(4)(iii) is added, paragraphs (g)(1) (i), 
(ii), and (iii), (g)(6) introductory text and (g)(6) (i) and (ii) are 
revised, paragraph (g)(7) is redesignated as paragraph (g)(9), and new 
paragraphs (g)(7) and (g)(8) are added to read as follows:


Sec. 413.86  Direct graduate medical education payments.

* * * * *
    (f) Determining the total number of FTE residents. * * *
    (4) * * *
    (iii) The hospital must incur all or substantially all of the costs 
for the training program in the nonhospital setting in accordance with 
the definition in paragraph (b) of this section.
    (g) Determining the weighted number of FTE residents. * * *
    (1) * * *
    (i) For residency programs other than those specified in paragraphs 
(g)(1)(ii) and (g)(1)(iii) of this section, the initial residency 
period is the minimum

[[Page 24750]]

number of years of formal training necessary to satisfy the 
requirements for initial board eligibility in the particular specialty 
for which the resident is training, as specified in the most recently 
published edition of the Graduate Medical Education Directory.
    (ii) For residency programs in osteopathy, dentistry, and podiatry, 
the minimum requirement for certification in a specialty or 
subspecialty is the minimum number of years of formal training 
necessary to satisfy the requirements of the appropriate approving body 
listed in Sec. 415.152 of this chapter.
    (iii) For residency programs in geriatric medicine accredited by 
the appropriate approving body listed in Sec. 415.152 of this chapter, 
these programs are considered approved programs on the later of--
    (A) The starting date of the program within a hospital; or
    (B) The hospital's cost reporting periods beginning on or after 
July 1, 1985.
* * * * *
    (6) If a hospital establishes a new medical residency training 
program as defined in paragraph (g)(9) of this section on or after 
January 1, 1995, the hospital's FTE cap described under paragraph 
(g)(4) of this section may be adjusted as follows:
    (i) If a hospital had no allopathic or osteopathic residents in its 
most recent cost reporting period ending on or before December 31, 
1996, and it establishes a new medical residency training program on or 
after January 1, 1995, the hospital's unweighted FTE resident cap under 
paragraph (g)(4) of this section may be adjusted based on the product 
of the highest number of residents in any program year during the third 
year of the first program's existence for all new residency training 
programs and the number of years in which residents are expected to 
complete the program based on the minimum accredited length for the 
type of program. The adjustment to the cap may not exceed the number of 
accredited slots available to the hospital for the new program.
    (A) If the residents are spending an entire program year (or years) 
at one hospital and the remainder of the program at another hospital, 
the adjustment to each respective hospital's cap is equal to the 
product of the highest number of residents in any program year during 
the third year of the first program's existence and the number of years 
the residents are training at each respective hospital.
    (B) Prior to the implementation of the hospital's adjustment to its 
FTE cap beginning with the fourth year of the hospital's residency 
program(s), the hospital's cap may be adjusted during each of the first 
3 years of the hospital's new residency program using the actual number 
of residents participating in the new program. The adjustment may not 
exceed the number of accredited slots available to the hospital for 
each program year.
    (C) Except for rural hospitals, the cap will not be adjusted for 
new programs established more than 3 years after the first program 
begins training residents.
    (D) Rural hospitals that qualify for an adjustment to its FTE cap 
under paragraph (g)(6)(i) of this section are permitted to be part of 
the same affiliated group for purposes of an aggregate FTE limit.
    (ii) If a hospital had allopathic or osteopathic residents in its 
most recent cost reporting period ending on or before December 31, 
1996, the hospital's unweighted FTE cap may be adjusted for new medical 
residency training programs established on or after January 1, 1995 and 
on or before August 5, 1997. The adjustment to the hospital's FTE 
resident limit for the new program is based on the product of the 
highest number of residents in any program year during the third year 
of the newly established program and the number of years in which 
residents are expected to complete each program based on the minimum 
accredited length for the type of program.
    (A) If the residents are spending an entire program year (or years) 
at one hospital and the remainder of the program at another hospital, 
the adjustment to each respective hospital's cap is equal to the 
product of the highest number of residents in any program year during 
the third year of the first program's existence and the number of years 
the residents are training at each respective hospital.
    (B) Prior to the implementation of the hospital's adjustment to its 
FTE cap beginning with the fourth year of the hospital's residency 
program, the hospital's cap may be adjusted during each of the first 3 
years of the hospital's new residency program, using the actual number 
of residents in the new programs. The adjustment may not exceed the 
number of accredited slots available to the hospital for each program 
year.
* * * * *
    (7) A hospital that began construction of its facility prior to 
August 5, 1997, sponsored new medical residency training programs, and 
temporarily trained those residents at another hospital(s) until the 
facility was completed may receive an adjustment to its FTE cap.
    (i) The newly constructed hospital's FTE cap is equal to the lesser 
of:
    (A) The product of the highest number of residents in any program 
year during the third year of the first program's existence for all new 
residency training programs and the number of years in which residents 
are expected to complete the programs based on the minimum accredited 
length for each type of program; or
    (B) The number of accredited slots available to the hospital for 
each year of the programs.
    (ii) If the medical residency training programs sponsored by the 
newly constructed hospital have been in existence for 3 years or more 
by the time the residents begin training at the newly constructed 
hospital, the newly constructed hospital's cap will be based on the 
number of residents training in the third year of the first of those 
programs begun at the temporary training site.
    (iii) If the medical residency training programs sponsored by the 
newly constructed hospital have been in existence for less than 3 years 
by the time the residents begin training at the newly constructed 
hospital, the newly constructed hospital's cap will be based on the 
number of residents training at the newly constructed hospital in the 
third year of the first of those programs (including the years at the 
temporary training site).
    (iv) The provisions of this paragraph (g)(7) are applicable during 
portions of cost reporting periods occurring on or after October 1, 
1999.
    (8) A hospital may receive a temporary adjustment to its FTE cap to 
reflect residents added because of another hospital's closure if the 
hospital meets the following criteria:
    (i) The hospital is training additional residents from a hospital 
that closed on or after July 1, 1996.
    (ii) At least 60 days before the hospital begins to train the 
residents, the hospital submits a request to its fiscal intermediary 
for a temporary adjustment to its FTE cap, documents that the hospital 
is eligible for this temporary adjustment by identifying the residents 
who have come from the closed hospital and have caused the hospital to 
exceed its cap, and specifies the length of time the adjustment is 
needed.
* * * * *

[[Page 24751]]

PART 483--REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES

    C. Part 483 is amended as set forth below:
    1. The authority citation for Part 483 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. In Sec. 483.20, the introductory text of paragraph (b)(2) is 
revised to read as follows:


Sec. 483.20  Resident assessment.

* * * * *
    (b) Comprehensive assessments.  * * *
    (2) When required. Subject to the timeframes prescribed in 
Sec. 413.343(b) of this chapter, a facility must conduct a 
comprehensive assessment of a resident in accordance with the 
timeframes specified in paragraphs (b)(2)(i) through (iii). However, 
the timeframes prescribed in Sec. 413.343(b) of this chapter do not 
apply to CAHs.
* * * * *

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

    D. Part 485 is amended as follows:
    1. The authority citation for Part 485 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. Section 485.618 is amended by revising paragraph (d) to read as 
follows:


Sec. 485.618  Conditions of participation: Emergency services.

* * * * *
    (d) Standard: Personnel. There must be a doctor of medicine or 
osteopathy, a physician assistant, or a nurse practitioner with 
training or experience in emergency care on call and immediately 
available by telephone or radio contact, and available on site within 
the following timeframes:
    (1) Within 30 minutes, on a 24-hour a day basis, if the CAH is 
located in an area other than an area described in paragraph (d)(2) of 
this section; or
    (2) Within 60 minutes, on a 24-hour a day basis, if the following 
requirements are met:
    (i) The CAH is located in an area designated as frontier (that is, 
an area having fewer than six residents per square mile based on the 
latest population data published by the Bureau of the Census) or in an 
area that meets criteria for a remote location adopted by the State in 
its rural health care plan, and approved by HCFA, under section 1820(b) 
of the Act;
    (ii) The State has determined under criteria in its rural health 
care plan that allowing an emergency response time longer than 30 
minutes is the only feasible method of providing emergency care to 
residents of the area served by the CAH; and
    (iii) The State maintains documentation showing that the response 
time of up to 60 minutes at a particular CAH it designates are 
justified because other available alternatives would increase the time 
needed to stabilize a patient in an emergency.
* * * * *
    3. In Sec. 485.645, the introductory text of paragraph (d) is 
republished and paragraph (d)(6) is revised to read as follows:


Sec. 485.645  Special requirements for CAH providers of long-term care 
services (``swing beds'').

* * * * *
    (d) SNF services.  CAH is substantially in compliance with the 
following SNF requirements contained in subpart B of part 483 of this 
chapter:
* * * * *
    (6) Comprehensive assessment, comprehensive care plan, and 
discharge planning (Sec. 483.20(b), (d), and (e) of this chapter, 
except that the CAH is not required to comply with the requirements for 
frequency, scope and number of assessments prescribed in 
Sec. 413.343(b)).
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance)

    Dated: April 9, 1999.
Nancy Ann DeParle,
Administrator, Health Care Financing Administration.

    Dated: April 26, 1999.
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, 1999; Payment Amounts 
for Blood Clotting Factor Effective for Discharges Occurring On or 
After October 1, 1999; and Update Factors and Rate-of-Increase 
Percentages Effective With Cost Reporting Periods Beginning On or 
After October 1, 1999

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, 1999, 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 yields the greatest aggregate payment: the Federal 
national rate, the updated hospital-specific rate based on FY 1982 cost 
per discharge, or the updated hospital-specific rate based on FY 1987 
cost per discharge. 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 for FY 2000. The changes, to be applied 
prospectively, would affect the calculation of the Federal rates. In 
section III of this addendum, we are proposing updates to the payments 
per unit for blood clotting factor provided to hospital inpatients who 
have hemophilia. We also are proposing to add another product (clotting 
factor, porcine (HCPCS code J7191)) to the list of clotting factors 
that would be paid under this benefit.
    In section IV of this addendum, we discuss our proposed changes for

[[Page 24752]]

determining the prospective payment rates for Medicare inpatient 
capital-related costs for FY 2000. Section V of this addendum sets 
forth our proposed changes for determining the rate-of-increase limits 
for hospitals excluded from the prospective payment system for FY 2000. 
The tables to which we refer in the preamble to the proposed rule are 
presented at the end of this addendum in section VI.

II. Proposed Changes to Prospective Payment Rates for Inpatient 
Operating Costs for FY 2000

    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, 1999. 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 2000.
    In summary, the proposed standardized amounts set forth in Tables 
1A and 1C of section VI of this addendum reflect--
     Updates of 0.9 percent for all areas (that is, the market 
basket percentage increase of 2.7 percent minus 1.8 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 1999 budget 
neutrality factor and applying a revised factor;
     An adjustment to apply the revised outlier offset by 
removing the FY 1999 outlier offsets and applying a new offset; and
     An adjustment in the Puerto Rico standardized amounts to 
reflect the application of a Puerto Rico-specific wage index.

A. Calculation of Adjusted Standardized Amounts

1. Standardization of Base-Year Costs or Target Amounts
    Section 1886(d)(2)(A) of the Act required the establishment of 
base-year cost data containing allowable operating costs per discharge 
of inpatient hospital services for each hospital. The preamble to the 
September 1, 1983 interim final rule (48 FR 39763) contains a detailed 
explanation of how base-year cost data were established in the initial 
development of standardized amounts for the prospective payment system 
and how they are used in computing the Federal rates.
    Section 1886(d)(9)(B)(i) of the Act required us to determine the 
Medicare target amounts 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 us to update 
base-year per discharge costs for FY 1984 and then standardize the cost 
data in order to remove the effects of certain sources of variation in 
cost among hospitals. These effects 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. The average labor share 
in Puerto Rico is 71.3 percent. We are proposing to revise the 
discharge-weighted national standardized amount for Puerto Rico to 
reflect the proportion of discharges in large urban and other areas 
from the FY 1998 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 1997 population estimates published by the Bureau of the 
Census, 61 areas meet the criteria to be defined as large urban areas 
for FY 2000. 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 areas' and the other areas' average standardized amounts for FY 
2000 using the applicable percentage increases specified in section 
1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XV) of the Act 
specifies that, for hospitals in all areas, the update factor for the 
standardized amounts for FY 2000 is equal to the market basket 
percentage increase minus 1.8 percentage points.
    The percentage change in the market basket reflects the average 
change in the price of goods and services purchased by hospitals to 
furnish inpatient care. The most recent forecast of the proposed 
hospital market basket increase for FY 2000 is 2.7 percent. Thus, for 
FY 2000,

[[Page 24753]]

the proposed update to the average standardized amounts equals 0.9 
percent.
    As in the past, we are adjusting the FY 1999 standardized amounts 
to remove the effects of the FY 1999 geographic reclassifications and 
outlier payments before applying the FY 2000 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 2000.
    Although the update factor for FY 2000 is set by law, we are 
required by section 1886(e)(3) of the Act to report to the Congress on 
our initial recommendation of update factors for FY 2000 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.
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 requires us to update the hospital 
wage index on an annual basis beginning October 1, 1993. This provision 
also requires us to make any updates or adjustments to the wage index 
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 1999 relative weights and wage index to aggregate payments 
using the proposed FY 2000 relative weights and wage index. The same 
methodology was used for the FY 1999 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 0.997393. We also 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 0.999910. These 
budget neutrality adjustment factors are applied to the standardized 
amounts without removing the effects of the FY 1999 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 apply these same adjustment 
factors to the hospital-specific rates that are effective for cost 
reporting periods beginning on or after October 1, 1999. (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. Based on these simulations, we are applying an 
adjustment factor of 0.994453 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 1999 budget neutrality adjustment 
factor. We note that the proposed FY 2000 adjustment reflects wage 
index and standardized amount reclassifications approved by the MGCRB 
or the Administrator as of February 26, 1999. The effects of any 
additional reclassification changes resulting from appeals and reviews 
of the MGCRB decisions for FY 2000 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 2000.
    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 1999, the fixed loss cost outlier threshold is equal to the 
prospective payment for the DRG plus $11,100 ($10,129 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 1999 standardized 
amounts of 0.948740 for the large urban and other areas rates and 
0.9392 for the capital Federal rate.
    In accordance with section 1886(d)(5)(A)(iv) of the Act, we 
calculated proposed outlier thresholds for FY 2000 so that outlier 
payments are projected to equal 5.1 percent of total payments based on 
DRG prospective

[[Page 24754]]

payment rates. In accordance with section 1886(d)(3)(E), we reduced the 
proposed FY 2000 standardized amounts by the same percentage to account 
for the projected proportion of payments paid to outliers. To calculate 
FY 2000 outlier thresholds, we simulated payments by applying FY 2000 
rates and policies to the December 1998 update of the FY 1998 MedPAR 
file and the December 1998 update of the provider-specific file. As we 
have explained in the past, to calculate outlier thresholds we apply a 
cost inflation factor to update costs for the cases used to simulate 
payments. 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, we 
used a cost inflation factor of minus 1.724 percent. To set the 
proposed FY 2000 outlier thresholds, we used a cost inflation factor 
(or cost adjustment factor) of zero percent. This factor reflects our 
analysis of the best available cost report data as well as calculations 
(using the best available data) indicating that the percentage of 
actual outlier payments for FY 1998, is higher than we projected before 
the beginning of FY 1998, and that the percentage of actual outlier 
payments for FY 1999 will likely be higher than we projected before the 
beginning of FY 1999. The calculations of ``actual'' outlier payments 
are discussed further below. Based on these simulations, we are 
proposing a fixed loss cost outlier threshold in FY 2000 equal to the 
prospective payment rate for the DRG plus $14,575 ($13,309 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.
    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 2000 will result in outlier 
payments equal to 5.1 percent of operating DRG payments and 6.0 percent 
of capital payments based on the Federal rate.
    The proposed outlier adjustment factors applied to the standardized 
amounts for FY 2000 are as follows:

------------------------------------------------------------------------
                                                 Operating     Capital
                                               standardized    Federal
                                                  amounts        rate
------------------------------------------------------------------------
National.....................................      0.948934       0.9397
Puerto Rico..................................      0.969184       0.9334
------------------------------------------------------------------------

    We apply the proposed outlier adjustment factors after removing the 
effects of the FY 1999 outlier adjustment factors on the standardized 
amounts.
    Table 8A in section VI 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 July 31, 1998 
final rule (63 FR 41099), effective October 1, 1999. 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 0.212473 greater than 1.280336 and capital 
cost-to-charge ratios lower than 0.0130310 or greater than 0.17166. 
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 2000 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 July 31, 1998 final rule (63 FR 41009), we stated that, 
based on available data, we estimated that actual FY 1998 outlier 
payments would be approximately 5.4 percent of actual total DRG 
payments. This was computed by simulating payments using actual FY 1997 
bill data available at the time. That is, the estimate of actual 
outlier payments did not reflect actual FY 1998 bills but instead 
reflected the application of FY 1998 rates and policies to available FY 
1997 bills. Our current estimate, using available FY 1998 bills, is 
that actual outlier payments for FY 1998 were approximately 6.5 percent 
of actual total DRG payments. We note that the MedPAR file for FY 1998 
discharges continues to be updated. Thus, the data indicate that, for 
FY 1998, the percentage of actual outlier payments relative to actual 
total payments is higher than we projected before FY 1998 (and thus 
exceeds the percentage by which we reduced the standardized amounts for 
FY 1998). In fact, the data indicate that the proportion of actual 
outlier payments for FY 1998 exceeds 6 percent. Nevertheless, 
consistent with the policy and statutory interpretation we have 
maintained since the inception of the prospective payment system, we do 
not plan to recoup money and make retroactive adjustments to outlier 
payments for FY 1998.
    We currently estimate that actual outlier payments for FY 1999 will 
be approximately 6.2 percent of actual total DRG payments, higher than 
the 5.1 percent we projected in setting outlier policies for FY 1999. 
This estimate is based on simulations using the December 1998 update of 
the provider-specific file and the December 1998 update of the FY 1998 
MedPAR file (discharge data for FY 1998 bills). We used these data to 
calculate an estimate of the actual outlier percentage for FY 1999 by 
applying FY 1999 rates and policies to available FY 1998 bills.
5. FY 2000 Standardized Amounts
    The adjusted standardized amounts are divided into labor and 
nonlabor portions. Table 1A contains the two national standardized 
amounts that we are proposing 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). The labor and nonlabor portions of the national average 
standardized amounts for Puerto Rico hospitals are set forth in Table 
1C. This table also includes the Puerto Rico standardized amounts.

B. Adjustments for Area Wage Levels and Cost of Living

    Tables 1A and 1C, as set forth in this addendum, contain the 
proposed labor-related and nonlabor-related shares that would be used 
to calculate the prospective payment rates for hospitals located in the 
50 States, the District of Columbia, and Puerto Rico. This section 
addresses two types of adjustments to the standardized amounts that are 
made in determining the prospective payment rates as described in this 
addendum.
1. Adjustment for Area Wage Levels
    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act requires 
that we make an adjustment to the labor-related portion of the 
prospective payment rates to account for area differences in hospital 
wage levels. This

[[Page 24755]]

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 this preamble, 
we discuss the data and methodology for the proposed wage index. The 
proposed 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 2000, 
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, 1999, we will publish them in the 
final rule and use them in determining FY 2000 payments.

 Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Alaska--All areas.............................................     1.25
Hawaii:
  County of Honolulu..........................................     1.25
  County of Hawaii............................................     1.15
  County of Kauai.............................................     1.225
  County of Maui..............................................     1.225
  County of Kalawao...........................................     1.225 
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office of
  Personnel Management.)

C. DRG Relative Weights

    As discussed in section II of the preamble, we have developed a 
classification system for all hospital discharges, assigning them into 
DRGs, and have developed relative weights for each DRG that reflect the 
resource utilization of cases in each DRG relative to Medicare cases in 
other DRGs. Table 5 of section VI of this addendum contains the 
relative weights that we propose to use for discharges occurring in FY 
2000. These factors have been recalibrated as explained in section II 
of the preamble.

D. Calculation of Prospective Payment Rates for FY 2000

General Formula for Calculation of Prospective Payment Rates for FY 
2000
    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, or, 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, 100 percent of the 
Federal rate plus 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, 1999 and before 
October 1, 2000, 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 Table 1A in section VI 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 VI 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 VI 
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 
2000. We are proposing to increase the hospital-specific rates by 0.9 
percent (the hospital market basket percentage increase of 2.7 percent 
minus 1.8 percentage points) for sole community hospitals and Medicare-
dependent, small rural hospitals located in all areas for FY 2000. 
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 2000, is the market basket rate of increase 
minus 1.8 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 
2000, is the market basket rate of increase minus 1.8 percentage 
points.
    b. Calculation of Hospital-Specific Rate. For sole community 
hospitals and

[[Page 24756]]

Medicare-dependent, small rural hospitals, the applicable FY 2000 
hospital-specific rate would be calculated by increasing the hospital's 
hospital-specific rate for the preceding fiscal year by the applicable 
update factor (0.9 percent), which is the same as the update for all 
prospective payment hospitals. In addition, the hospital-specific rate 
would be adjusted by the budget neutrality adjustment factor (that is, 
0.997393) 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, 1999, 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, 1999 
and Before October 1, 2000.
    a. Puerto Rico Rate. The Puerto Rico prospective payment rate is 
determined as follows:
    Step 1--Select the appropriate adjusted average standardized amount 
considering the large urban or other designation of the hospital (see 
Table 1C of section VI 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 VI 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 VI of the addendum).
    b. National Rate. The national prospective payment rate is 
determined as follows:
    Step 1--Multiply the labor-related portion of the national average 
standardized amount (see Table 1C of section VI of the addendum) by the 
appropriate national wage index (see Tables 4A and 4B of section VI of 
the addendum).
    Step 2--Add the amount from Step 1 and the nonlabor-related portion 
of the national average standardized amount.
    Step 3--Multiply the result in Step 2 by 50 percent.
    Step 4--Multiply the amount from Step 3 by the appropriate DRG 
relative weight (see Table 5 of section VI 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 the Payment Rates for Blood Clotting 
Factor for Hemophilia Inpatients

    As discussed in our August 29, 1997 final rule with comment period 
(62 FR 46002) and our May 12, 1998 final rule (63 FR 26327), section 
4452 of Public Law 105-33 amended section 6011(d) of Public Law 101-239 
to reinstate the add-on payment for the costs of administering blood 
clotting factor to Medicare beneficiaries who have hemophilia and who 
are hospital inpatients for discharges occurring on or after October 1, 
1997.
    We are proposing to calculate the add-on payment for FY 2000 using 
the same methodology we described in the August 29, 1997 and May 12, 
1998 final rules. That is, we are proposing to establish a price per 
unit of clotting factor based on the average wholesale price (AWP). To 
identify the AWP, we are using the most recent data available from 
First DataBank, a commercial source of AWPs in electronic format. The 
add-on payment amount for each clotting factor, as described by HCFA's 
Common Procedure Coding System (HCPCS), is based on the median AWP of 
the several products available in that category of factor, discounted 
by 15 percent.
    We also are proposing to add HCPCS code J7191 (clotting factor, 
porcine) to the list of clotting factors that will be paid under this 
benefit. This code was recently reestablished in the HCPCS coding 
system because it represents a unique product that is different from 
the other clotting factors listed.
    Based on the methodology described above, we are proposing the 
following prices per unit of factor for FY 2000:

J7190  Factor VIII (antihemophilic factor, human)................   0.79
J7191  Factor VIII (antihemophilic factor, porcine)..............   1.87
J7192  Factor VIII (antihemophilic factor, recombinant)..........   1.03
J7194  Factor IX (complex).......................................   0.45
J7196  Other hemophilia clotting factors (for example, anti-        1.43
 inhibitors).....................................................
Q0160  Factor IX (antihemophilic factor, purified,                  0.97
 nonrecombinant).................................................
Q0161  Factor IX (antihemophilic factor, purified, recombinant)..   1.00
 

    These prices for blood clotting factor administered to inpatients 
who have hemophilia would be effective for discharges beginning on or 
after October 1, 1999 through September 30, 2000. Payment will be made 
for blood clotting factor only if there is an ICD-9-CM diagnosis code 
for hemophilia included on the bill.

IV. Proposed Changes to Payment Rates for Inpatient Capital-Related 
Costs for FY 2000

    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 2000. The rates would be effective for 
discharges occurring on or after October 1, 1999.
    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 that 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

[[Page 24757]]

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 requires that for discharges occurring on or after October 
1, 1997, and before October 1, 2002, the unadjusted standard Federal 
rate is reduced by 17.78 percent. A small part of that reduction will 
be restored effective October 1, 2002. As a result of the February 25, 
1999 final rule (64 FR 9378), the Federal rate changed effective March 
1, 1999, because of revisions to the GAF.
    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. For 
discharges occurring on or after October 1, 1997, and before October 1, 
2002, the unadjusted hospital-specific rate is reduced by 17.78 
percent. A small part of this reduction will 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

    In the July 31, 1998 final rule (63 FR 41011) we established a 
capital Federal rate of $378.05 for FY 1999. As of the March 1, 1999 
revision, the Federal rate for FY 1999 is $378.10. As a result of the 
changes we are proposing to the factors used to establish the Federal 
rate in this preamble, the proposed FY 2000 Federal rate is $374.31.
    In the discussion that follows, we explain the factors that were 
used to determine the proposed FY 2000 capital Federal rate. In 
particular, we explain why the proposed FY 2000 Federal rate has 
decreased 1.00 percent compared to the FY 1999 Federal rate. Even 
though the proposed FY 2000 Federal capital rate is less than the FY 
1999 Federal rate, we estimate aggregate capital payments will increase 
by 2.66 percent during this same period. This increase is primarily due 
to the increase in the Federal blend percentage from 80 to 90 percent 
for fully prospective payment hospitals.
    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 2000 compared to FY 1999.
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 2000 under that framework is -0.6 percent. This 
proposal is based on a projected 0.5 percent increase in the CIPI, a 
-0.7 percent adjustment for the FY 1998 DRG reclassification and 
recalibration, and a forecast error correction of -0.4 percent. We 
explain the basis for the FY 2000 CIPI projection in section II.D of 
this addendum. Here we describe the policy adjustments that have been 
applied.
    The case-mix index is the measure of the average DRG weight for 
cases paid under the prospective payment system. Because the DRG weight 
determines the prospective payment for each case, any percentage 
increase in the case-mix index corresponds to an equal percentage 
increase in hospital payments.
    The case-mix index can change for any of several reasons:
     The average resource use of Medicare patients changes 
(``real'' case-mix change);
     Changes in hospital coding of patient records result in 
higher weight DRG assignments (``coding effects''); and
     The annual DRG reclassification and recalibration changes 
may not be budget neutral (``reclassification effect'').
    We define real case-mix change as actual changes in the mix (and 
resource requirements) of Medicare patients as opposed to changes in 
coding behavior that result in assignment of cases to higher-weighted 
DRGs but do not reflect higher resource requirements. In the update 
framework for the prospective payment system for operating costs, we 
adjust the update upwards to allow for real case-mix change, but remove 
the effects of coding changes on the case-mix index. We also remove the 
effect on total payments of prior changes to the DRG classifications 
and relative weights, in order to retain budget neutrality for all 
case-mix index-related changes other than patient severity. (For 
example, we adjusted for the effects of the FY 1998 DRG 
reclassification and

[[Page 24758]]

recalibration as part of our FY 2000 update recommendation.) We have 
adopted this case-mix index adjustment in the capital update framework 
as well.
    For FY 2000, we are projecting a 0.5 percent increase in the case-
mix index. We estimate that real case-mix increase will equal 0.5 
percent in FY 2000. Therefore, the proposed net adjustment for case-mix 
change in FY 2000 is 0.0 percentage points.
    We estimate that FY 1998 DRG reclassification and recalibration 
resulted in a 0.7 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. Therefore, we 
are making a -0.7 percent adjustment for DRG reclassification and 
recalibration in the proposed update for FY 2000.
    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 and the forecast used in calculating the 
update factors. In setting a prospective payment rate under the 
framework, we make an adjustment for forecast error only if our 
estimate of the change in the capital input price index 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. A forecast 
error of -0.4 percentage points was calculated for the FY 1998 update. 
That is, current historical data indicate that the FY 1998 CIPI used in 
calculating the forecasted FY 1998 update factor overstated realized 
price increases by 0.4 percent. Therefore, we are making a -0.4 percent 
adjustment for forecast error in the proposed update for FY 2000.
    Under the capital prospective payment system update 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. Therefore, we have 
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 2000, we have developed a Medicare-specific intensity 
measure based on a 5-year average using FY 1994-1998 data. In 
determining case-mix constant intensity, we found that observed case-
mix increase was 0.8 percent in FY 1994, 1.7 percent in FY 1995, 1.6 
percent in FY 1996, 0.3 percent in FY 1997, and -0.4 percent in FY 
1998. 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 1994 through FY 1998. Based on this analysis, we believe 
that all of the observed case-mix increase for FY 1994, FY 1997 and FY 
1998 is real. The increases for FY 1995 and FY 1996 were in excess of 
our estimate of real case mix increase.
    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 0.8 percent for FY 1994, 1.0 percent for FY 1995, 1.0 
percent for FY 1996, 0.3 percent for FY 1997, and -0.4 for FY 1998, we 
estimate that case-mix constant intensity declined by an average 1.3 
percent during FYs 1994 through 1998, for a cumulative decrease of 6.3 
percent. If we assume that real case-mix increase was 0.8 percent for 
FY 1994, 1.4 percent for FY 1995, 1.4 percent for FY 1996, 0.3 percent 
for FY 1997, and -0.4 for FY 1998, we estimate that case-mix constant 
intensity declined by an average 1.5 percent during FYs 1994 through 
1998, for a cumulative decrease of 7.1 percent. Since we estimate that 
intensity has declined during that period, we are recommending a 0.0 
percent intensity adjustment for FY 2000.
    b. Comparison of HCFA and MedPAC Update Recommendations. MedPAC 
recommends a -1.1 to 1.8 percent update to the standard capital Federal 
rate and we are recommending a -0.6 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 that 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 a 
financing policy 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 0.5 
percent, and the percentage change in MedPAC's market basket is 1.9 
percent.
    MedPAC and HCFA also differ in the adjustments they make to their 
price indices. (See Table 1 for a comparison

[[Page 24759]]

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. For the FY 2000 update, the Commission is 
also including a site-of-care substitution adjustment to account for 
the decline in the average length of Medicare acute inpatient stays. 
This adjustment is designed to shift funding along with associated 
costs when Medicare patients are discharged to postacute settings that 
replace acute impatient days. Other factors, such as technological 
advances that allow for a decreased need in follow-up care and BBA 
mandated policy on payment for transfer cases that limits payments 
within certain DRGs, are reflected in the site-of-care substitution 
adjustment as well. A negative intensity adjustment would capture the 
site of care substitution accounted for in MedPAC's update framework. 
However, we did not make a negative adjustment for intensity this year. 
We may examine the appropriateness of adopting a negative intensity 
adjustment at a later date.
    MedPAC recommends a -1.8 to a -0.9 adjustment for site-of-care 
substitutions for FY 2000. For FY 2000, MedPAC recommends a -1.0 to a 
0.0 adjustment for productivity. We recommend a 0.0 intensity 
adjustment. Additionally, since long-term interest rates are low by 
historical standards, MedPAC recommends a -0.3 to a 0.0 adjustment to 
the update for FY 2000, to reflect changes in the real interest rates.
    We recommend a 0.0 total case mix adjustment since we are 
projecting a 0.5 percent increase in the case mix index and we estimate 
that real case-mix increase will equal 0.5 percent in FY 2000. 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 0.0 
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 has recommended 
a -1.1 to 1.8 percent update to the capital Federal rate for FY 2000. 
MedPAC believes that the annual updates to the capital and operating 
payments under the prospective payment system should not differ 
substantially, even though they are determined separately, since they 
correspond to costs generated by providing the same inpatient hospital 
services to the same Medicare patients. This range for the capital 
update is consistent with the prospective payment system operating 
update range of 0.0 to 2.6 recommended by the Commission. We describe 
the basis for our proposed -0.6 percent total update in the preceding 
section. Our recommendation is within the range recommended by MedPAC.
    Also, MedPAC argued that the distinction between inpatient 
operating and capital payment rates is arbitrary and does not foster 
efficient overall decision making about the allocation of resources. 
Accordingly, MedPAC recommended that once the transition to fully 
perspective capital payment is completed, a single PPS payment rate 
should be developed for hospital inpatient services to Medicare 
beneficiaries. MedPAC indicated that a single PPS payment rate for both 
operating and capital PPS costs would be consistent with the way that 
hospitals purchase a majority of goods and services.
    We responded to a similar comment in the July 31, 1998 final rule 
(63 FR 41013) and in the September 1, 1995 final rule (60 FR 45816). In 
those rules, we stated that our long-term goal was to develop a single 
update framework for operating and capital prospective payments and 
that we would begin development of a unified framework. We indicated 
that, in the meantime, we would maintain as much consistency as 
possible between the current operating and capital frameworks in order 
to facilitate the eventual development of a unified framework. In 
addition, we stated that because of the similarity of the update 
frameworks, the update frameworks could be combined without too much 
difficulty. We maintain our goal of combining the update frameworks at 
the end of the capital transition period and may examine combining the 
payment systems after the conclusion of the capital prospective payment 
transition period.

   Table 1.--HCFA's FY 2000 Update Factor and MedPAC's Recommendation
------------------------------------------------------------------------
                                                 HCFA's
                                                 update      MedPAC's
                                                 factor   recommendation
------------------------------------------------------------------------
Capital Input Price Index Financing Policy           0.5             1.9
 Adjustment..................................
    Financing Policy Adjustment..............  .........     -0.3 to 0.0
Policy Adjustment Factors:
    Productivity.............................  .........     -1.0 to 0.0
    Intensity................................        0.0  ..............
        Science and Technology...............  .........      0.5 to 1.0
        Intensity............................  .........             (1)
        Real within DRG Change...............  .........             (2)
    Site-of-Care Substitution................  .........    -1.8 to -0.9
                                              --------------------------
            Subtotal.........................        0.0     -2.3 to 0.1
Case-Mix Adjustment Factors:                   .........  ..............
    Projected Case-Mix Change................       -0.5  ..............
    Real Across DRG Change...................        0.5  ..............
    Coding Change............................  .........             0.0
    Real within DRG Change...................        (3)      0.0 to 0.2
                                              --------------------------
            Subtotal.........................        0.0      0.0 to 0.2
Effect of FY 1998 Reclassification and               0.7  ..............
 Recalibration...............................
Forecast Error Correction....................       -0.4            -0.4
                                              ==========================

[[Page 24760]]

 
            Total Update.....................       -0.6     -1.1 to 1.8
------------------------------------------------------------------------
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, 90 
percent for cost reporting periods beginning in FY 2000 for hospitals 
paid under the fully prospective payment 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 July 31, 1998 final rule, we estimated that outlier payments 
for capital in FY 1999 would equal 6.08 percent of inpatient capital-
related payments based on the Federal rate (63 FR 41013). Accordingly, 
we applied an outlier adjustment factor of 0.9392 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 6.03 
percent of inpatient capital-related payments based on the Federal rate 
in FY 2000. Therefore, we are proposing an outlier adjustment factor of 
0.9397 to the Federal rate. Thus, estimated capital outlier payments 
for FY 2000 represent a lower percentage of total capital standard 
payments than in FY 1999.
    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 2000 is 1.0005 (0.9397/0.9392). 
The outlier adjustment increases the FY 2000 Federal rate by 0.05 
percent compared with the FY 1999 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 1999, we calculated a GAF/DRG budget neutrality factor of 
1.0027. In the February 25, 1999 final rule (64 FR 9381), we adopted an 
incremental GAF/DRG budget neutrality factor of 1.0028 for discharges 
on or after March 1, 1999. For FY 2000, we are proposing a GAF/DRG 
budget neutrality factor of 0.9986. 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 1999 to FY 2000 is 0.9986. The 
proposed cumulative change in the rate due to this adjustment is 1.0015 
(the product of the incremental factors for FY 1993, FY 1994, FY 1995, 
FY 1996, FY 1997, FY 1998, FY 1999, and the proposed incremental factor 
for FY 2000: 0.9980  x  1.0053  x  0.9998  x  0.9994  x  0.9987  x  
0.9989  x  1.0028  x  0.9986 = 1.0015).
    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 2000 geographic reclassification decisions 
made by the MGCRB compared to FY 1999 decisions. However, it does not 
account for changes in payments due to changes in the DSH and IME 
adjustment factors or in the large urban add-on.
4. Exceptions Payment Adjustment Factor
    Section 412.308(c)(3) requires that the standard Federal rate for 
inpatient capital-related costs be reduced by an adjustment factor 
equal to the estimated proportion of additional payments for exceptions 
under Sec. 412.348 relative to total payments under the hospital-
specific rate and Federal rate. We use the model originally developed 
for determining the budget neutrality adjustment factor to determine 
the exceptions payment adjustment factor. We describe that model in 
Appendix B to this proposed rule.
    For FY 1999, we estimated that exceptions payments would equal 2.17 
percent of aggregate payments based on the Federal rate and the 
hospital-specific rate. Therefore, we applied an exceptions reduction 
factor of 0.9783 (1-0.0217) in determining the Federal rate. For this 
proposed rule, we estimate that exceptions payments for FY 2000 will 
equal 2.48 percent of aggregate payments based on the Federal rate and 
the hospital-specific rate. Therefore, we are proposing an exceptions 
payment reduction factor of 0.9752 to the Federal rate for FY 2000. The 
proposed

[[Page 24761]]

exceptions reduction factor for FY 2000 is 0.32 percent lower than the 
factor for FY 1999.
    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 2000 
Federal rate is 0.9752/0.9783, or 0.9968.
5. Standard Capital Federal Rate for FY 2000
    For FY 1999 (effective March 1, 1999), the capital Federal rate was 
$378.10. As a result of changes we are proposing to the factors used to 
establish the Federal rate, the proposed FY 2000 Federal rate is 
$374.31. The proposed Federal rate for FY 2000 was calculated as 
follows:
     The proposed FY 2000 update factor is 0.9940; that is, the 
proposed update is -0.60 percent.
     The proposed FY 2000 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 0.9986.
     The proposed FY 2000 outlier adjustment factor is 0.9397.
     The proposed FY 2000 exceptions payments adjustment factor 
is 0.9752.
    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 2000 affected the computation of the proposed FY 
2000 Federal rate in comparison to the FY 1999 Federal rate. The 
proposed FY 2000 update factor has the effect of decreasing the Federal 
rate by 0.60 percent compared to the rate in FY 1999, while the 
proposed geographic and DRG budget neutrality factor has the effect of 
decreasing the Federal rate by 0.14 percent. The proposed FY 2000 
outlier adjustment factor has the effect of increasing the Federal rate 
by 0.05 percent compared to FY 1999. The proposed FY 2000 exceptions 
reduction factor has the effect of decreasing the Federal rate by 0.32 
percent compared to the exceptions reduction for FY 1999. The combined 
effect of all the proposed changes is to decrease the proposed Federal 
rate by 1.00 percent compared to the Federal rate for FY 1999.

          Comparison of Factors and Adjustments: FY 1999 Federal Rate and Proposed FY 2000 Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                                           Proposed FY                 Percent
                                                                FY 1999        2000        Change       change
----------------------------------------------------------------------------------------------------------------
Update factor 1.............................................       1.0010       0.9940       0.9940        -0.60
GAF/DRG Adjustment Factor 1.................................       1.0028       0.9986       0.9986        -0.14
Outlier Adjustment Factor 2.................................       0.9392       0.9397       1.0005         0.05
Exceptions Adjustment Factor 2..............................       0.9783       0.9752       0.9968        -0.32
Federal Rate................................................      $378.10      $374.31       0.9900       -1.00
----------------------------------------------------------------------------------------------------------------
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 1999 to FY 2000 resulting from the application of the 0.9986 GAF/DRG
  budget neutrality factor for FY 2000 is 0.9986.
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 2000 outlier reduction factor is 0.9397/0.9392, or 1.0005.

6. Special Rate for Puerto Rico Hospitals
    As explained at the beginning of section IV of this Addendum, 
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 in 1998, we 
also propose to apply separate budget neutrality adjustments for the 
national GAF and for the Puerto Rico GAF. We apply the same budget 
neutrality factor for DRG reclassifications and recalibration 
nationally and for Puerto Rico. The Puerto Rico GAF budget neutrality 
factor is 1.0015, while the DRG adjustment is 1.0001, for a combined 
cumulative adjustment of 1.0016.
    In computing the payment for a particular Puerto Rico hospital, the 
Puerto Rico portion of the rate (50 percent) 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 percent) 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 1999, before 
application of the GAF, the special rate for Puerto Rico hospitals was 
$181.10. With the changes we are proposing to the factors used to 
determine the rate, the proposed FY 2000 special rate for Puerto Rico 
is $174.15.

B. Determination of Hospital-Specific Rate Update

    Section 412.328(e) of the regulations provides that the hospital-
specific rate for FY 2000 be determined by adjusting the FY 1999 
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 2000, we are proposing that the hospital-
specific rate be updated by a factor of 0.9940.
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 2000, we estimate that

[[Page 24762]]

exceptions payments will be 2.48 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 
0.9752. 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 2000 hospital-specific rate is 0.9752/0.9783, or 0.9968.
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 1999 and FY 2000 and 
the net adjustment for each factor. It also shows that the proposed 
cumulative net adjustment from FY 1999 to FY 2000 is 0.9908, which 
represents a proposed decrease of 0.92 percent to the hospital-specific 
rate. For each hospital, the proposed FY 2000 hospital-specific rate is 
determined by multiplying the FY 1999 hospital-specific rate by the 
cumulative net adjustment of 0.9908.

                       Proposed FY 2000 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
                                                                           Proposed FY      Net        Percent
                                                                FY 1999        2000      adjustment     change
----------------------------------------------------------------------------------------------------------------
Update Factor...............................................       1.0010       0.9940       0.9940        -0.60
Exceptions Payment Adjustment Factor........................       0.9783       0.9752       0.9968        -0.32
Cumulative Adjustments......................................       0.9793       0.9703       0.9908       -0.92
----------------------------------------------------------------------------------------------------------------
 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 1999 to FY 2000 is 0.9940. In contrast, the exceptions
  payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the
  exceptions reduction factor from FY 1999 to FY 2000 is 0.9752/0.9783, or 0.9968.

C. Calculation of Inpatient Capital-Related Prospective Payments for FY 
2000

    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 reduction factor for that fiscal year; and,
     For the payment adjustment factors applicable to the 
hospital (that is, the hospital's GAF, the disproportionate share 
adjustment factor, and the indirect medical 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 
2000 are 90 percent of the adjusted Federal rate and 10 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 90 percent 
of the Federal rate for discharges occurring in cost reporting periods 
beginning during FY 2000. Thus, a fully prospective hospital will 
receive 90 percent of the capital-related outlier payment calculated 
for the case for discharges occurring in cost reporting periods 
beginning in FY 2000. 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 2000 are in section II.A.4.c 
of this

[[Page 24763]]

Addendum. For FY 2000, 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 $14,575.
    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 2000 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), June 2, 1997 (62 
FR 29953), August 29, 1997 (62 FR 46050), May 8, 1998 (63 FR 25619), 
and July 31, 1998 (63 FR 41017).
2. Forecast of the CIPI for Federal Fiscal Year 2000
    We are forecasting the CIPI to increase 0.5 percent for FY 2000. 
This reflects a projected 1.6 percent increase in vintage-weighted 
depreciation prices (building and fixed equipment, and movable 
equipment) and a 3.2 percent increase in other capital expense prices 
in FY 2000, partially offset by a 3.2 percent decline in vintage-
weighted interest rates in FY 2000. The weighted average of these three 
factors produces the 0.5 percent increase for the CIPI as a whole.

V. 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 regulations at Sec. 413.40. Under 
these limits, a hospital-specific 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 hospital unit, rehabilitation 
hospital or hospital unit, or long-term care hospital, the target 
amount may not exceed the updated figure for the 75th percentile of 
target amounts for hospitals and units in the same class (psychiatric, 
rehabilitation, and long-term care) for cost reporting periods ending 
during FY 1996. 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-specific target amount is adjusted annually, at the 
beginning of each hospital's cost reporting period, by an applicable 
update factor.
    Section 1886(b)(3)(B) of the Act, which is implemented in 
regulations at Sec. 413.40(c)(3)(vii), provides that for cost reporting 
periods beginning on or after October 1, 1999 and before October 1, 
2000, the update factor depends on the hospital's or hospital 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

[[Page 24764]]

percent of the ceiling, the update factor is 0.
    The most recent forecast of the market basket increase for FY 2000 
for hospitals and hospital units excluded from the prospective payment 
system is 2.6 percent. Therefore, the update to a hospital's target 
amount for its cost reporting period beginning in FY 2000 would be 
between 0 and 2.6 percent.
    In addition, Sec. 413.40(c)(4)(iii) requires that for cost 
reporting periods beginning on or after October 1, 1999 and before 
October 1, 2000, the target amount for each psychiatric hospital or 
hospital unit, rehabilitation hospital or hospital unit, and long-term 
care hospital cannot exceed a cap on the target amounts for hospitals 
in the same class. For cost reporting periods beginning in FY 2000, the 
proposed caps are $11,076 for psychiatric hospitals and hospital units, 
$20,071 for rehabilitation hospitals and hospital units, and $39,596 
for long-term care hospitals. Regulations at Sec. 413.40(d) specify the 
formulas for determining bonus and relief payments for excluded 
hospitals and specify established criteria for an additional bonus 
payment for continuous improvement. Regulations at 
Sec. 413.40(f)(2)(ii) specify the payment methodology for new hospitals 
and hospital units (psychiatric, rehabilitation, and long-term care) 
effective October 1, 1997.

VI. Tables

    This section contains the tables referred to throughout the 
preamble to this proposed rule and in this Addendum. For purposes of 
this proposed rule, and to avoid confusion, we have retained the 
designations of Tables 1 through 5 that were first used in the 
September 1, 1983 initial prospective payment final rule (48 FR 39844). 
Tables 1A, 1C, 1D, 3C, 4A, 4B, 4C, 4D, 4E, 4F, 5, 7A, 7B, 8A, and 8B 
are presented below. The tables presented below are as follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor
Table 1D--Capital Standard Federal Payment Rate
Table 3C--Hospital Case Mix Indexes for Discharges Occurring in Federal 
Fiscal Year 1998 and Hospital Average Hourly Wage for Federal Fiscal 
Year 2000 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 7A--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 98 MEDPAR Update 12/98 GROUPER V16.0
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 98 MEDPAR Update 12/98 GROUPER V17.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban 
and Rural Hospitals (Case Weighted) March 1999

   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
------------------------------------------------------------------------
          Large urban areas                       Other areas
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
       2,804.51           1,139.95           2,760.12          1,121.90
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                         Large urban areas                  Other areas
                                                 ---------------------------------------------------------------
                                                       Labor         Nonlabor          Labor         Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................        2,780.77        1,130.30        2,780.77        1,130.30
Puerto Rico.....................................        1,335.82          537.70        1,314.67          529.19
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                                 Rate
------------------------------------------------------------------------
National...................................................       374.31
Puerto Rico................................................       174.15
------------------------------------------------------------------------

                                                                 
                                                                                                 
                                                                                                 
                                                                                                 
                                
                                
                                
                                
                                
                                
                                

[[Page 24765]]


Table 3C.--Hospital Case Mix Indexes for Discharges Occurring in Federal
 Fiscal Year 1998; Hospital Average Hourly Wage for Federal Fiscal Year
                             2000 Wage Index
------------------------------------------------------------------------
                                                                   Avg.
                         Prov.                          Case mix  hourly
                                                          index    wage
------------------------------------------------------------------------
010001................................................    1.4554   15.85
010004................................................    0.9916   15.02
010005................................................    1.1743   16.26
010006................................................    1.4464   17.31
010007................................................    1.1415   14.80
010008................................................    1.1818   17.65
010009................................................    1.0947   17.53
010010................................................    1.0813   15.91
010011................................................    1.5845   20.63
010012................................................    1.2638   19.30
010015................................................    1.0478   18.35
010016................................................    1.2449   16.13
010018................................................    0.9705   18.96
010019................................................    1.2752   15.49
010021................................................    1.2478   14.63
010022................................................    0.9572   20.51
010023................................................    1.6841   16.26
010024................................................    1.4253   16.03
010025................................................    1.3495   14.53
010027................................................    0.8128   14.93
010029................................................    1.5973   16.41
010031................................................    1.4197   18.02
010032................................................    0.8709   12.65
010033................................................    1.9994   19.23
010034................................................    1.0469   14.73
010035................................................    1.2391   17.48
010036................................................    1.0924   22.58
010038................................................    1.2343   18.33
010039*...............................................    1.6327   18.81
010040................................................    1.4992   19.10
010043................................................    1.0500   16.20
010044................................................    1.0251   17.02
010045................................................    1.1784   15.01
010046................................................    1.4732   17.18
010047................................................    0.9281   16.38
010049................................................    1.1802   14.48
010050................................................    1.0767   15.42
010051................................................    0.8974    9.94
010052................................................    1.0154   13.86
010053................................................    1.0510   13.18
010054................................................    1.1343   17.12
010055................................................    1.4214   18.19
010056................................................    1.3310   19.08
010058................................................    1.0341   12.78
010059................................................    1.0571   18.19
010061................................................    1.1108   15.92
010062................................................    1.0103   13.57
010064................................................    1.7507   20.90
010065................................................    1.3275   15.64
010066................................................    0.8966   12.07
010068................................................    1.3058   18.74
010069................................................    1.1341   13.57
010072................................................    1.0767   14.35
010073................................................    0.8779   12.83
010078................................................    1.2917   17.71
010079................................................    1.1849   16.87
010080................................................  ........   13.85
010081................................................    1.6352   10.92
010083................................................    1.0573   16.21
010084................................................    1.5014   18.78
010085................................................    1.3174   23.43
010086................................................    1.0101   14.93
010087................................................    1.7240   18.39
010089................................................    1.2016   16.61
010090................................................    1.6543   18.11
010091................................................    0.9852   16.36
010092................................................    1.4229   16.25
010094................................................    1.1553   18.56
010095................................................    1.0478   11.90
010097................................................    0.8658   12.90
010098................................................    0.9903   14.28
010099................................................    1.1704   15.93
010100................................................    1.2946   15.48
010101................................................    1.0189   15.42
010102................................................    0.9304   12.73
010103................................................    1.8373   19.09
010104................................................    1.6940   17.84
010108................................................    1.1487    8.43
010109................................................    1.0505   14.09
010110................................................    0.9677   15.91
010112................................................    1.1430   15.11
010113................................................    1.6124   17.24
010114................................................    1.2547   17.26
010115................................................    0.8486   13.75
010118................................................    1.2460   17.93
010119................................................    0.8454   18.17
010120................................................    0.9887   17.03
010121................................................    1.2837   15.18
010123................................................    1.1677   18.16
010124................................................    1.2293   16.27
010125................................................    1.0592   14.42
010126................................................    1.1226   17.64
010127................................................    1.3140   19.61
010128................................................    0.9181   12.57
010129................................................    1.0657   14.43
010130................................................    1.0438   16.35
010131................................................    1.3316   17.91
010134................................................    0.8091   10.78
010138................................................    0.9201   12.13
010139................................................    1.6352   19.95
010143................................................    1.2331   15.67
010144................................................    1.4122   17.12
010145................................................    1.3320   19.99
010146................................................    1.1893   18.86
010148................................................    0.9793   14.64
010149................................................    1.2499   17.08
010150................................................    1.0444   16.87
010152................................................    1.2458   15.08
010155................................................    1.0820   16.70
020001................................................    1.5225   27.97
020001................................................    0.8749  ......
020002................................................    1.0518   26.91
020004................................................    1.1822   26.40
020005................................................    0.8955   29.01
020006................................................    1.1279   26.77
020007................................................    0.8238   24.96
020009................................................    0.8160   23.18
020010................................................    0.9401   18.64
020011................................................    0.9160   29.47
020012................................................    1.2784   23.92
020013................................................    0.9595   26.82
020014................................................    1.1175   24.09
020014................................................    1.4452   18.50
020017................................................    1.4913   24.97
020018................................................    0.9175  ......
020019................................................    0.7991  ......
020021................................................    0.7833  ......
020024................................................    1.1070   22.73
020025................................................    0.8911   27.15
020026................................................    1.2510  ......
020027................................................    0.9446  ......
030001................................................    1.2609   19.47
030002................................................    1.8047   21.41
030003................................................    2.2773   23.68
030004................................................    0.9879   17.73
030006................................................    1.5274   17.64
030007................................................    1.2554   18.56
030008................................................    2.1835  ......
030009................................................    1.2480   17.93
030010................................................    1.3865   18.80
030011................................................    1.4370   20.08
030012................................................    1.2400   19.28
030012................................................    1.3439   17.62
030013................................................    1.2707   21.02
030014................................................    1.5090   19.47
030016................................................    1.2344   20.56
030017................................................    1.4184   19.80
030018................................................    1.8588   18.91
030019................................................    1.2360   19.91
030022................................................    1.4920   15.79
030023................................................    1.4956   22.44
030024*...............................................    1.7461   21.86
030025................................................    0.9555   17.67
030027................................................    0.9637   17.56
030030................................................    1.6444   21.62
030033................................................    1.2359   16.84
030034................................................    0.9867   19.09
030035................................................    1.1565   19.72
030036................................................    1.2807   18.94
030037................................................    2.0840   21.43
030038................................................    1.6154   22.08
030040................................................    1.0766   17.97
030041................................................    0.8876   17.44
030043................................................    1.2210   20.58
030044................................................    0.8783   16.47
030047................................................    0.8953   19.69
030049................................................    0.8732   19.09
030054................................................    0.8646   14.49
030055................................................    1.2321   18.28
030059................................................    1.2861   21.05
030060................................................    1.1438   16.77
030061................................................    1.6876   17.35
030062................................................    1.1773   17.48
030064................................................    1.7545   18.54
030065................................................    1.8106   19.93
030067................................................    1.0273   15.62
030068................................................    1.0198   17.35
030069................................................    1.3658   19.00
030071................................................    0.9615  ......
030073................................................    1.0330  ......
030074................................................    0.8723  ......
030075................................................    0.8002  ......
030076................................................    0.8839  ......

[[Page 24766]]

 
030077................................................    0.8563  ......
030078................................................    1.1466  ......
030079................................................    0.9065  ......
030080................................................    1.3765   19.99
030083................................................    1.2782   23.64
030084................................................    1.1334  ......
030085................................................    1.4665   17.84
030087................................................    1.6818   20.39
030088................................................    1.3654   19.58
030089................................................    1.6757   19.50
030092................................................    1.5829   21.56
030093................................................    1.4182   19.47
030094................................................    1.2704   19.78
030095................................................    1.1383   14.25
030099................................................    0.9405   18.07
030100................................................    2.0377  ......
030101................................................    1.4091  ......
030102................................................    2.6049  ......
040001................................................    1.0898   15.57
040002................................................    1.1548   14.09
040003................................................    1.1009   14.00
040004................................................    1.6240   17.29
040005................................................    1.0392   12.88
040007................................................    1.6923   19.52
040008................................................    1.0369   12.70
040011................................................    0.9437   12.27
040014................................................    1.3239   15.39
040015................................................    1.2153   14.60
040016................................................    1.6757   17.54
040017................................................    1.1681   14.95
040018................................................    1.2213   17.56
040019................................................    1.0343   25.71
040020................................................    1.6155   14.81
040021................................................    1.1803   16.28
040022................................................    1.4732   16.00
040024................................................    0.9967   15.73
040025................................................    0.9089   10.95
040026................................................    1.5803   18.24
040027................................................    1.2533   14.54
040028................................................    1.0058   12.84
040029................................................    1.2994   17.78
040030................................................    0.8774   14.15
040032................................................    0.9640   13.33
040035................................................    0.9449   11.21
040036................................................    1.4553   17.91
040037................................................    1.0573   13.48
040039................................................    1.2280   13.84
040040................................................    0.9016   17.43
040041................................................    1.2600   13.36
040041................................................    1.3395   22.59
040042................................................    1.1970   14.66
040044................................................    1.0388   11.44
040045................................................    1.0120   18.77
040047................................................    1.0272   16.39
040048................................................  ........   15.82
040050................................................    1.1538   11.79
040051................................................    1.0863   16.28
040053................................................    1.0741   15.82
040054................................................    0.9793   15.04
040055................................................    1.4239   16.10
040058................................................    1.0515   15.67
040060................................................    0.9756   11.47
040062................................................    1.6588   17.28
040064................................................    1.0572   12.40
040066................................................    1.0456   17.64
040067................................................    1.0993   13.49
040069................................................    1.0282   16.11
040070................................................    0.9322   15.48
040071................................................    1.6635   16.12
040072................................................    1.0381   15.84
040074................................................    1.2312   17.38
040075................................................    1.0116   12.75
040076................................................    1.0811   18.55
040077................................................    1.0517   12.46
040078................................................    1.5208   17.86
040080................................................    1.0062   15.74
040081................................................    0.8665   10.68
040082................................................    1.0845   16.51
040084................................................    1.1071   17.25
040085................................................    1.1521   15.78
040088................................................    1.3888   15.67
040090................................................    0.8936   17.55
040091................................................    1.1718   17.04
040093................................................    0.9205   12.90
040100................................................    1.1466   14.97
040105................................................    0.9914   14.24
040106................................................    0.9670   15.40
040107................................................    1.0684   19.62
040109................................................    1.1501   13.98
040114................................................    1.8323   18.31
040116................................................    1.1343   19.57
040118................................................    1.4187   17.43
040119................................................    1.1546   14.62
040124................................................    1.0493   17.25
040126................................................    0.9485   11.68
040132................................................  ........   13.18
040134................................................    2.7108  ......
040135................................................    2.3711  ......
050002................................................    1.4958   27.60
050006................................................    1.4137   19.53
050007................................................    1.4826   29.54
050008................................................    1.4218   25.86
050009................................................    1.6817   26.25
050013................................................    1.9898   24.85
050014................................................    1.2086   24.53
050015................................................    1.4488   25.38
050016................................................    1.1530   20.15
050017*...............................................    2.0931   23.63
050018................................................    1.3662   14.66
050021................................................  ........   28.50
050022................................................    1.6635   22.55
050024................................................    1.3224   20.34
050025*...............................................    1.7835   20.30
050026*...............................................    1.5148   28.57
050028................................................    1.3534   16.45
050029................................................    1.4007   23.29
050030................................................    1.3133   21.01
050033................................................    1.4634   24.56
050036................................................    1.7263   20.47
050038................................................    1.3484   27.83
050039................................................    1.6233   22.25
050040................................................    1.1965   30.67
050042................................................    1.2702   22.23
050043................................................    1.4929   33.51
050045................................................    1.2651   20.73
050046................................................    1.1767   26.35
050047................................................    1.5561   29.44
050051................................................    1.1204   17.84
050054................................................    1.1916   19.37
050055................................................    1.2420   29.09
050056................................................    1.3412   23.82
050057................................................    1.6051   21.27
050058................................................    1.4966   25.37
050060................................................    1.5503   20.92
050061................................................    1.4118   23.74
050063*...............................................    1.3493   23.07
050065................................................    1.6823   21.18
050066................................................    1.3020   21.42
050067................................................    1.2472   21.30
050068................................................    1.1039   28.48
050069................................................    1.6089   29.30
050070................................................    1.2353   32.60
050071................................................    1.3248   33.14
050072................................................    1.3875   32.97
050073................................................    1.2629   34.61
050074................................................    0.8073  ......
050075................................................    1.3484   33.52
050076................................................    2.0314   33.88
050077................................................    1.5621   23.22
050078................................................    1.2974   25.98
050079................................................    1.4850   30.03
050082................................................    1.6712   21.70
050084................................................    1.6107   23.10
050088................................................    0.9686   24.06
050089................................................    1.3384   19.12
050090................................................    1.2640   23.81
050091................................................    1.0925   22.22
050092................................................    0.8469   15.38
050093................................................    1.5659   24.08
050095................................................  ........   33.38
050096................................................    1.1356   21.67
050097................................................    1.5113   22.61
050099................................................    1.4590   23.66
050100................................................    1.6407   30.06
050101................................................    1.3575   30.01
050102................................................    1.3583   21.29
050103*...............................................    1.5762   25.38
050104................................................    1.4490   25.44
050107................................................    1.4605   21.76
050108................................................    1.8355   26.46
050109................................................  ........   26.48
050110................................................    1.2159   20.18
050111................................................    1.2944   21.74
050112................................................    1.3623   26.31
050113................................................    1.3163   27.73
050114................................................    1.3788   25.91
050115................................................    1.4961   20.94
050116................................................    1.5241   24.81
050117................................................    1.3978   20.44
050118................................................    1.1846   23.94
050121................................................    1.2928   18.94
050122................................................    1.5685  ......
050124................................................    1.2796   23.02

[[Page 24767]]

 
050125................................................    1.3663   24.04
050126................................................    1.4556   23.84
050127................................................    1.2518   19.76
050128................................................    1.6084   24.18
050129................................................    1.7494   13.86
050131................................................    1.2640   29.06
050132................................................    1.3640   22.91
050133................................................    1.2704   24.40
050135................................................    1.4808   27.03
050136................................................    1.3536   24.43
050137................................................    1.2990   30.07
050138................................................    2.0444   37.41
050139................................................    1.2535   31.38
050140................................................    1.3204   33.66
050144................................................    1.4207   25.75
050145................................................    1.3756   33.06
050146................................................    1.5841  ......
050148................................................    1.1044   21.06
050149................................................    1.4969   21.91
050150................................................    1.2679   23.48
050152................................................    1.3293   28.42
050153................................................    1.6402   29.59
050155................................................    1.0988   22.94
050158................................................    1.2998   27.67
050159................................................    1.3323   25.21
050167................................................    1.3726   21.68
050168................................................    1.5375   24.56
050169................................................    1.4739   24.64
050170................................................    1.4500   22.20
050172................................................    1.2520   17.70
050173................................................    1.3744   23.33
050174................................................    1.7008   31.21
050175................................................    1.2719   27.38
050177................................................    1.1869   20.25
050179................................................    1.2306   19.29
050180................................................    1.5813   32.19
050183................................................    1.2743   19.98
050186................................................    1.3455   21.91
050188................................................    1.4391   27.44
050189................................................    0.9661   23.24
050191................................................    1.4683   19.96
050193................................................    1.1582   23.73
050194................................................    1.2312   28.27
050195................................................    1.5639   34.54
050196................................................    1.2815   16.69
050197................................................    1.9562   31.26
050204................................................    1.5299   24.39
050205................................................    1.2841   24.02
050211................................................    1.3183   31.15
050213................................................    1.5713   20.73
050214................................................    1.5448   20.87
050215................................................    1.5700   29.63
050215................................................    1.2334   23.00
050217................................................    1.2876   19.89
050219................................................    1.1425   25.47
050219................................................  ........   26.32
050222................................................    1.5157   27.04
050224................................................    1.5832   23.79
050225................................................    1.5625   20.93
050225................................................    1.0612   20.15
050226................................................    1.3274   24.24
050228................................................    1.3089   30.16
050230................................................    1.4112   25.30
050231................................................    1.6440   25.63
050232................................................    1.5636   23.38
050233................................................  ........   31.40
050234................................................    1.1512   27.98
050235................................................    1.5544   25.86
050236................................................    1.5146   26.27
050238................................................    1.5288   24.00
050239*...............................................    1.5967   20.55
050240................................................    1.5246   25.18
050241................................................    1.1378   27.22
050242................................................    1.4446   30.14
050243................................................    1.5312   22.91
050245................................................    1.5041   22.10
050248................................................    1.2054   25.99
050251................................................    1.1113   18.50
050253................................................    1.4184   19.76
050254................................................    1.1991   19.69
050256................................................    1.7681   21.74
050257................................................    0.9509   19.59
050260................................................    0.9690   23.52
050261................................................    1.2103   20.45
050262................................................    1.8148   28.30
050264................................................    1.3466   29.45
050267................................................    1.6936   24.75
050270................................................    1.3630   23.83
050272................................................    1.3986   21.44
050274................................................    0.9467   21.19
050276................................................    1.1725   28.51
050276................................................    1.4351   23.14
050277................................................    1.4815   22.31
050278................................................    1.5070   23.84
050279................................................    1.2886   21.06
050280................................................    1.6534   24.46
050282................................................    1.3492   23.98
050286................................................    0.9172   17.80
050289................................................    1.7279   28.87
050290................................................    1.6741   26.37
050291................................................    1.1709   26.49
050292................................................    1.1236   22.38
050293................................................    1.0656   19.18
050295................................................    1.4569   20.28
050296................................................    1.2171   25.32
050298................................................    1.3268   20.52
050299................................................    1.3252   25.26
050300................................................    1.4143   22.46
050301................................................    1.2326   26.03
050302................................................  ........   29.19
050305................................................    1.5862   32.71
050307................................................    1.2747   24.39
050308................................................    1.5099   28.40
050309................................................    1.2834   24.40
050310................................................  ........   20.62
050312................................................    1.9696   23.79
050313................................................    1.1560   23.10
050315................................................    1.3473   21.92
050317................................................  ........   19.45
050320................................................    1.2371   30.56
050324................................................    2.0030   26.27
050327................................................    1.6651   22.32
050329................................................    1.2991   19.54
050331................................................    1.3646   25.53
050334................................................    1.7493   32.02
050335................................................    1.4570   21.04
050336................................................    1.3561   20.10
050342................................................    1.2512   21.90
050343................................................    0.9711   17.24
050348................................................    1.7865   20.71
050349................................................    0.8866   15.05
050350................................................    1.4046   23.77
050351................................................    1.4821   24.94
050352................................................    1.3151   23.59
050353................................................    1.6183   23.25
050355................................................    0.8385   17.16
050357................................................    1.3583   23.64
050359................................................    1.2481   20.40
050360................................................    1.4309   31.76
050366................................................    1.3334   21.40
050367................................................    1.2586   29.48
050369................................................    1.3031   19.87
050373................................................    1.4037   21.92
050376................................................    1.4260   25.30
050377................................................    1.0300   25.64
050377................................................    0.8258  ......
050378................................................    1.0916   22.24
050379................................................    1.0223   16.90
050380................................................    1.6105   30.58
050382................................................    1.3610   21.00
050385................................................    1.3408   25.92
050388................................................    0.8708   13.20
050390................................................    1.1966   22.39
050391................................................    1.3438   22.42
050392................................................    0.9321   21.93
050394................................................    1.5689   22.32
050396................................................    1.6448   23.63
050397................................................    0.9378   20.77
050401................................................    1.1055   17.78
050404................................................    1.0623   19.28
050406................................................    1.0266   17.12
050407................................................    1.2842   30.12
050410................................................    1.0721   16.47
050411................................................    1.3571   32.24
050414................................................    1.3002   24.34
050417................................................    1.3224   21.89
050419................................................    1.3788   23.12
050420................................................    1.3048   22.68
050421................................................    1.2343  ......
050423................................................    1.0115   22.33
050424................................................    1.8351   23.78
050425................................................    1.2290   33.69
050426................................................    1.3912   23.71
050427................................................    0.9378   20.07
050430................................................    1.0036   21.14
050432................................................    1.5223   21.50
050433................................................    0.9711   16.80
050434................................................    1.0630   15.63
050435................................................    1.1647   32.99
050436................................................    1.0075   16.36
050436................................................    0.9233   18.33
050438................................................    1.7365   24.08
050440................................................    1.2718   30.82

[[Page 24768]]

 
050441................................................    1.9387   29.05
050443................................................    0.8693   16.43
050444................................................    1.3199   24.67
050446................................................    0.8088   20.54
050447................................................    1.0794   18.34
050448................................................    1.1060   20.08
050449................................................    1.2885   22.13
050454*...............................................    1.7746   28.69
050455................................................    1.7950   19.92
050455................................................    1.2816   23.39
050456................................................    1.2213   17.62
050457................................................    1.9135   31.18
050459................................................    1.5161   37.09
050464................................................    1.7086   22.31
050468................................................    1.5610   23.17
050469................................................    1.1462   19.84
050470................................................    1.1450   17.03
050470................................................    1.2419   24.35
050471................................................    1.8998   24.29
050476................................................    1.3673   23.14
050477................................................    1.4363   27.71
050478................................................    0.9815   23.05
050481................................................    1.3946   22.95
050482................................................    1.0697   16.93
050483................................................    2.2575   21.60
050483................................................    1.5954   26.32
050485................................................    1.6061   23.70
050486................................................  ........   24.50
050488................................................    1.3254   32.86
050491................................................    1.1970   24.15
050492................................................    1.4174   21.42
050494................................................    1.2385   25.41
050496................................................    1.7580   33.02
050498................................................    1.2265   24.87
050502................................................    1.7255   22.63
050503................................................    1.3465   23.59
050506................................................    1.3628   21.22
050510................................................    1.2780   33.46
050512................................................    1.4414   34.31
050515................................................    1.3431   35.04
050516................................................    1.5018   25.14
050517................................................    1.2038   20.37
050522................................................    1.1580   31.73
050523................................................    1.2445   28.42
050526................................................    1.2949   23.19
050528................................................    1.1896   18.69
050531................................................    1.1101   20.73
050534................................................    1.2830   23.31
050535................................................    1.5228   24.23
050537................................................    1.3702   22.21
050539................................................    1.3242   22.78
050541................................................    1.5636   34.62
050542................................................    0.9778   19.06
050543................................................    0.8445   20.38
050545................................................    0.7605   27.57
050546................................................    0.6961   27.76
050547................................................    0.9021   27.08
050548................................................  ........   26.59
050549................................................    1.6004   27.34
050550................................................    1.3676   25.54
050551................................................    1.3528   24.05
050552................................................    1.2749   22.87
050557................................................    1.5186   21.92
050559................................................    1.2852   24.67
050561................................................    1.2134   33.93
050564................................................    1.3221   24.51
050565................................................    1.3123   22.88
050567................................................    1.5510   24.23
050568................................................    1.3424   20.73
050569................................................    1.2039   24.94
050570................................................    1.6495   24.50
050571................................................    1.3940   24.37
050573................................................    1.5642   25.14
050575................................................    1.1445  ......
050577................................................    1.3610   20.52
050578................................................    1.2810   30.24
050579................................................    1.4312   30.07
050581................................................    1.4505   23.58
050583................................................    1.6150   23.36
050584................................................    1.2149   23.16
050585................................................    1.2567   26.50
050586................................................    1.3530   23.84
050588................................................    1.2804   30.39
050590................................................    1.3223  ......
050591................................................    1.3152   22.29
050592................................................    1.2657   26.05
050594................................................    1.6258   22.78
050597................................................    1.2269   22.78
050598................................................    1.3408   28.11
050601................................................    1.6473   32.87
050603................................................    1.4112   22.61
050604................................................    1.4593   33.32
050607................................................  ........   24.10
050608................................................    1.2805   16.15
050609................................................    1.4876   31.93
050613................................................    1.1408   22.73
050615................................................    1.5445   23.61
050616................................................    1.3408   22.80
050618................................................    1.0867   21.70
050623................................................    1.6040   30.32
050624................................................    1.3287   20.88
050625................................................    1.6313   24.43
050630................................................    1.2732   24.10
050633................................................    1.2945   21.98
050635................................................  ........   37.85
050636................................................    1.4342   20.83
050638................................................    1.1056   23.63
050641................................................    1.2985   21.30
050643................................................    0.9493  ......
050644................................................    1.0737   23.12
050660................................................    1.4981  ......
050661................................................  ........   20.48
050662................................................    0.8152   28.29
050663................................................    1.1713   23.71
050667................................................    1.0811   24.11
050668................................................    1.1187   39.90
050670................................................    0.7555   21.88
050674................................................    1.2384   36.24
050675................................................    2.2195   15.84
050676................................................    1.0018   17.53
050677................................................    1.3671   33.71
050678................................................    1.2889   19.79
050680................................................    1.1161   27.32
050682................................................    0.9235   17.97
050684................................................    1.2411   21.81
050685................................................    1.1904   32.13
050686................................................    1.2873   33.25
050688................................................    1.1889   30.00
050689................................................    1.4877   34.19
050690................................................    1.4194   33.83
050693................................................    1.3143   33.30
050694................................................    1.3869   22.23
050695................................................    1.0637   23.52
050696................................................    2.1089   26.41
050697................................................    1.3282   21.47
050699................................................    0.5913   28.48
050700................................................  ........   28.45
050701................................................    1.3166   27.62
050702................................................  ........   12.25
050704................................................    1.0850   20.76
050707................................................    0.9714   27.51
050708................................................    1.4521   21.91
050709................................................    1.2542   19.42
050710................................................    1.3382   26.81
050713................................................    0.7909   15.30
050714................................................    1.3545  ......
050715................................................  ........   19.12
050717................................................    1.2615  ......
050718................................................    0.7586  ......
050719................................................    3.1984  ......
050720................................................    0.9144  ......
060001................................................    1.6827   19.81
060003................................................    1.2712   19.32
060004................................................    1.2022   21.79
060006................................................    1.2559   17.86
060007................................................    1.1616   16.38
060008................................................    1.0845   17.09
060009................................................    1.5000   21.18
060010................................................    1.6680   22.72
060011................................................    1.3912   22.01
060012................................................    1.3799   19.77
060013................................................    1.3198   19.14
060014................................................    1.8158   20.45
060015................................................    1.6295   23.57
060016................................................    1.1644   15.96
060018................................................    1.2890   22.76
060020................................................    1.6161   17.73
060022................................................    1.5680   19.65
060023................................................    1.6349   19.68
060024................................................    1.7013   21.98
060027................................................    1.6853   21.67
060028................................................    1.5673   22.25
060029................................................    0.8934   21.41
060030................................................    1.3522   20.03
060031................................................    1.5399   19.40
060032................................................    1.4830   22.37
060033................................................    1.1419   13.82
060034................................................    1.5815   21.41
060036................................................    1.1374   19.24
060037................................................    1.0041   14.05
060038................................................    0.9494   14.31
060041................................................    0.9290   14.83
060042................................................    1.0390   20.08

[[Page 24769]]

 
060043................................................    0.8765   13.05
060044................................................    1.1677   18.54
060046................................................    1.0277   20.44
060047................................................    0.9573   15.12
060049................................................    1.3269   20.83
060050................................................    1.2499   16.80
060052................................................    1.0358   12.55
060053................................................    1.0148   14.94
060054................................................    1.4104   19.39
060056................................................    0.9009   17.05
060057................................................    1.0271   23.38
060058................................................    0.9425   16.91
060058................................................    1.3708   24.88
060060................................................    0.9192   14.89
060062................................................    0.8672   14.94
060063................................................  ........   15.09
060064................................................    1.4858   20.93
060065................................................    1.2927   24.30
060066................................................    0.9930   14.07
060068................................................  ........   19.64
060070................................................    1.1240   16.58
060071................................................    1.2070   16.95
060073................................................    0.9583   15.84
060075................................................    1.2386   22.85
060076................................................    1.4334   19.29
060087................................................  ........   21.03
060088................................................    1.0054   16.67
060090................................................    0.9024   14.51
060096................................................    1.1102   23.11
060100................................................    1.5342   22.00
060103................................................    1.3190   22.34
060104................................................    1.2281   22.30
060107................................................    1.1971   13.64
060109................................................    1.0979  ......
070001................................................    1.7556   26.51
070002................................................    1.8370   25.46
070003................................................    1.1151   26.09
070004................................................    1.2021   17.57
070005................................................    1.4405   25.57
070006................................................    1.3841   28.71
070007................................................    1.3504   20.38
070008................................................    1.2547   26.03
070010................................................    1.6964   25.94
070011................................................    1.3837   18.74
070012................................................    1.1748   23.84
070015................................................    1.3856   21.37
070016................................................    1.4249   26.23
070017................................................    1.3692   25.33
070018................................................    1.3688   28.88
070019................................................    1.1852   24.70
070020................................................    1.3279   25.66
070021................................................    1.2354   27.20
070022................................................    1.8624   25.08
070024................................................    1.3266   24.98
070025*...............................................    1.8697   21.03
070026................................................  ........   18.79
070027................................................    1.3119   23.11
070028................................................    1.5539   24.76
070029................................................    1.3338   22.75
070030................................................    1.2872   25.55
070031................................................    1.2430   21.66
070033................................................    1.4104   28.06
070034................................................    1.3899   27.67
070035................................................    1.4195   23.06
070036................................................    1.7249   28.95
070038................................................    0.7820  ......
070039................................................    0.9541   29.07
080001................................................    1.7050   25.28
080001................................................    1.3001   16.14
080002................................................  ........   15.60
080003................................................    1.3859   22.40
080004................................................    1.2655   19.76
080005................................................  ........   14.43
080006................................................    1.2940   22.26
080007................................................    1.4146   20.38
090001................................................    1.6063   25.97
090002................................................    1.3508   19.70
090003*...............................................    1.3694   28.74
090004................................................    1.7901   24.54
090006................................................    1.3157   20.08
090007................................................    1.3060   21.66
090008................................................    1.5079   21.25
090010................................................    1.0721   15.87
090011................................................    2.1212   27.37
100001*...............................................    1.5321   17.59
100002................................................    1.4384   21.32
100004................................................    1.0139   15.25
100006................................................    1.6140   20.63
100007................................................    1.8868   21.89
100008................................................    1.6004   20.72
100009................................................    1.4674   24.29
100010................................................    1.5057   21.91
100012................................................    1.6358   18.17
100014................................................    1.4840   19.83
100015................................................    1.4801   18.24
100017................................................    1.5926   17.77
100018................................................    1.5487   21.46
100019................................................    1.5570   19.81
100020................................................    1.3913   26.18
100022*...............................................    1.7896   25.89
100023................................................    1.3582   21.11
100024................................................    1.3508   20.78
100025................................................    1.7579   19.12
100026................................................    1.5828   20.78
100027................................................    1.0140   12.94
100028................................................    1.2109   19.75
100029................................................    1.3427   19.18
100030................................................    1.2532   18.82
100032................................................    1.8549   19.32
100034................................................    1.7609   18.23
100035................................................    1.5876   19.58
100038................................................    1.6639   24.78
100039................................................    1.5294   20.25
100040................................................    1.7522   18.37
100043................................................    1.3301   17.46
100044................................................    1.3902   21.14
100045................................................    1.3907   20.04
100046................................................    1.4313  ......
100047................................................    1.8501   18.89
100048................................................    0.9391   13.50
100049................................................    1.2657   18.57
100050................................................    1.1486   16.60
100051................................................    1.2376   18.84
100052................................................    1.3877   16.19
100053................................................    1.2157   18.71
100054................................................    1.2782   18.19
100055................................................    1.3757   17.62
100056................................................    1.4971   23.65
100057................................................    1.3578   18.92
100060................................................    1.8350   22.39
100060................................................    1.5612   21.03
100061................................................    1.4669   21.79
100062................................................    1.7286   17.96
100063................................................    1.1599   16.23
100067................................................    1.3589   17.40
100068................................................    1.3616   18.65
100070................................................    1.4351   20.33
100071................................................    1.2326   16.48
100072................................................    1.2524   19.22
100073................................................    1.7197   18.16
100075................................................    1.5968   18.05
100076................................................    1.3003   16.25
100077................................................    1.3909   19.62
100078................................................    1.0296   18.15
100079................................................    1.3325  ......
100080................................................    1.6003   21.16
100081................................................    1.1021   13.83
100082................................................    1.4970   19.80
100084................................................    1.3481   20.40
100085................................................    1.4397   21.08
100086................................................    1.2342   21.16
100087................................................    1.8333   22.84
100088................................................    1.6475   19.90
100088................................................    1.3183   18.47
100090................................................    1.3787   17.88
100092................................................    1.5757   18.19
100093................................................    1.5959   16.63
100098................................................    1.0984   19.03
100099................................................    1.2201   15.30
100102................................................    1.0153   19.33
100103................................................    0.9381   18.10
100105................................................    1.4533   21.50
100106................................................    1.0265   19.31
100107................................................    1.3135   18.01
100108................................................    0.9981   11.47
100109................................................    1.3849   22.76
100110................................................    1.3691   19.64
100112................................................    0.9729    9.77
100113................................................    1.9447   22.26
100114................................................    1.3410   23.45
100117................................................    1.1881   18.73
100118................................................    1.2985   19.76
100121................................................    1.1822   19.34
100122................................................    1.2062   18.06
100124................................................    1.2948   18.95
100125................................................    1.2698   17.33
100126................................................    1.4687   17.90
100127................................................    1.6571   19.87
100128................................................    2.2008   21.37
100129................................................    1.2934   18.57
100130................................................    1.1799   19.10
100131................................................    1.3441   22.17
100132................................................    1.2951   16.90

[[Page 24770]]

 
100134................................................    0.9749   13.47
100135................................................    1.5663   18.14
100137................................................    1.2769   19.05
100138................................................    1.0055   11.01
100139................................................    1.0923   15.64
100140................................................    1.2176   17.39
100142................................................    1.2184   18.68
100144................................................    1.1622   15.02
100145................................................  ........   19.11
100146................................................    0.9700   17.87
100146................................................    1.3080   19.02
100147................................................    1.0087   14.68
100150................................................    1.3244   21.02
100151................................................    1.7633   19.41
100154................................................    1.5916   19.85
100156................................................    1.1116   17.13
100159................................................    0.9604   16.38
100160................................................    1.2033   21.63
100161................................................    1.7011   21.50
100162................................................    1.3957   19.52
100165................................................    1.1517   15.32
100166................................................    1.4343   19.96
100167................................................    1.3554   21.81
100168................................................    1.3364   20.13
100169................................................    1.7635   20.78
100170*...............................................    1.4176   15.12
100172................................................    1.4427   15.18
100173................................................    1.6517   17.34
100174................................................    1.3757   20.51
100175................................................    1.1552   16.74
100176................................................    2.0762   24.70
100177................................................    1.2940   22.00
100179................................................    1.7112   20.91
100180................................................    1.4416   18.48
100181................................................    1.1072   24.57
100183................................................    1.1925   20.84
100187................................................    1.4354   20.69
100189................................................    1.3293   21.01
100199................................................    1.3519   23.37
100200................................................    1.2394   22.26
100203................................................  ........   18.86
100204................................................    1.6275   19.93
100206................................................    1.3738   20.31
100207................................................  ........   15.92
100208................................................    1.3742   20.83
100209................................................    1.4794   19.73
100210................................................    1.5725   19.18
100211................................................    1.3995   25.53
100212................................................    1.6223   25.34
100213................................................    1.5101   19.12
100217................................................    1.2750   19.87
100220................................................    1.6359   19.82
100221................................................    1.8123   27.48
100222................................................    0.9440   21.20
100223................................................    1.4649   18.76
100224................................................    1.3348   24.70
100225................................................    1.3371   20.64
100226................................................    1.3524   24.83
100228................................................    1.2825   23.70
100229................................................    1.3301   18.21
100230................................................    1.3524   20.60
100231................................................    1.6807   17.40
100232................................................    1.2520   17.32
100234................................................    1.2585   21.58
100235................................................  ........   17.66
100236................................................    1.3919   15.54
100237................................................    2.1914   22.93
100238................................................    1.5456   17.63
100239................................................    1.4273   19.76
100240................................................    1.0888   17.93
100241................................................    0.8966   13.83
100242................................................    1.4285   17.12
100243................................................    1.4081   20.24
100244................................................    1.3741   17.41
100246................................................    1.3684   21.10
100248................................................    1.5873   31.86
100252................................................    1.2004   17.87
100253................................................    1.4328   20.60
100254................................................    1.5393   20.91
100255................................................    1.2547   21.02
100256................................................    2.0100   24.26
100258................................................    1.6900   21.88
100259................................................    1.3406   19.86
100260................................................    1.4566   21.20
100262................................................    1.3401   19.59
100263................................................  ........   16.90
100264................................................    1.3627   17.61
100265................................................    1.2933   19.80
100266................................................    1.3562   17.73
100267................................................    1.3062   17.10
100268................................................    1.1954   23.59
100269................................................    1.4338   21.20
100270................................................    1.0126   19.86
100271................................................    1.7709   19.92
100275................................................    1.3951   21.33
100276................................................    1.2359   21.98
100277................................................    1.0352   16.14
100279................................................    1.2735   21.84
100280................................................    1.2949   16.58
100281................................................    1.2798   22.02
100282................................................    1.0837   18.66
100284................................................    1.0788  ......
110001................................................    1.2556   17.87
110002................................................    1.2532   17.37
110003................................................    1.3668   16.02
110004................................................    1.3570   20.11
110005................................................    1.1963   19.26
110006................................................    1.4200   20.13
110007................................................    1.6126   14.39
110008................................................    1.2429   18.26
110009................................................    1.1330   14.82
110010................................................    2.1782   24.55
110011................................................    1.1632   18.28
110013................................................    1.0596   16.03
110014................................................    0.9440   16.12
110015................................................    1.1403   19.48
110016................................................    1.2276   15.77
110017................................................    0.9321   10.54
110018................................................    1.1960   21.04
110020................................................    1.1927   18.44
110023................................................    1.3373   18.54
110024................................................    1.3655   19.75
110025................................................    1.3797   18.65
110026................................................    1.1361   16.14
110027................................................    1.1146   14.83
110028................................................    1.7778   19.89
110029................................................    1.3534   20.05
110030................................................    1.2999   17.68
110031................................................    1.2251   21.58
110032................................................    1.2506   16.19
110033................................................    1.4221   22.19
110034................................................    1.5852   18.24
110035................................................    1.3916   20.98
110036................................................    1.8560   23.78
110038................................................    1.4425   16.38
110039................................................    1.4188   20.77
110040................................................    1.0642   16.40
110041................................................    1.1822   16.69
110042................................................    1.1544   20.55
110043................................................    1.8078   17.16
110044................................................    1.1887   19.60
110045................................................    1.1386   19.94
110046................................................    1.2456   19.23
110048................................................    1.2374   15.65
110049................................................    1.0998   14.21
110050................................................    1.1806   18.76
110051................................................    1.0250   15.75
110052................................................  ........   15.06
110054................................................    1.3606   19.32
110056................................................    1.0843   16.50
110059................................................    1.2164   17.70
110061................................................    1.0960   13.72
110062................................................    0.9058   12.21
110063................................................    1.0542   17.97
110064................................................    1.4839   18.24
110065................................................    1.0322   13.32
110066................................................    1.4496   20.65
110069................................................    1.2569   18.35
110070................................................    1.1398   18.23
110071................................................    1.0981   14.83
110072................................................    0.9722   12.43
110073................................................    1.1437   15.14
110074................................................    1.4973   20.04
110075................................................    1.3226   17.01
110076................................................    1.4639   20.40
110078................................................    1.7586   24.70
110079................................................    1.4465   20.14
110080................................................    1.3579   23.43
110082................................................    2.0915   22.01
110083*...............................................    1.7615   21.27
110086................................................    1.2837   14.98
110087................................................    1.3551   20.54
110089................................................    1.2041   18.58
110091................................................    1.2791   21.38
110092................................................    1.0878   15.09
110094................................................    0.9920   13.87
110095................................................    1.3537   15.95
110096................................................    1.0806   16.32
110097................................................    1.0653   15.62
110098................................................    0.9870   14.04
110100................................................    1.0558   20.38
110101................................................    1.1014   11.73
110103................................................    0.9309   11.94

[[Page 24771]]

 
110104................................................    1.0963   15.32
110105................................................    1.2997   16.52
110107................................................    1.8897   17.41
110108................................................    0.9511   15.14
110109................................................    1.1080   20.99
110111................................................    1.2038   17.37
110112................................................    0.9917   19.13
110113................................................    1.0478   15.19
110114................................................    1.0441   15.13
110115................................................    1.7526   24.79
110118................................................    1.1376   15.40
110120................................................    1.0386   16.08
110121................................................    1.2784   15.58
110122................................................    1.3818   18.82
110124................................................    1.2091   17.13
110125................................................    1.2562   17.33
110127................................................    0.8873   13.76
110128................................................    1.1933   18.97
110130................................................    1.0064   13.08
110132................................................    1.1478   15.02
110134................................................    0.9656   11.56
110135................................................    1.3363   17.07
110136................................................    1.0986   16.17
110140................................................    1.0445   17.88
110141................................................    0.9996   12.51
110142................................................    0.9525   12.30
110142................................................    0.9525   12.30
110142................................................    1.0382   12.54
110143................................................    1.4339   21.45
110144................................................    1.0712   17.98
110146................................................    1.0854   17.61
110150................................................    1.4073   18.77
110152................................................    1.0430   14.77
110153................................................    1.0912   18.69
110154................................................    0.9773   14.81
110155................................................    1.1399   17.14
110156................................................    1.0511   15.14
110161................................................    1.3149   20.87
110162................................................    0.7514  ......
110163................................................    1.4628   18.99
110164................................................    1.4190   19.40
110165................................................    1.4270   19.00
110166................................................    1.4482   19.85
110168................................................    1.6676   19.82
110169................................................    1.2028   18.72
110171................................................    1.6118   20.18
110172................................................    1.3576   25.44
110174................................................    0.9161   14.30
110176................................................    3.7291   22.39
110177................................................    1.5099   19.66
110178................................................  ........   16.92
110179................................................    1.1507   20.38
110181................................................    0.9038   13.72
110183................................................    1.3120   21.44
110184................................................    1.2434   20.72
110185................................................    1.1874   16.25
110186................................................    1.2548   17.21
110187................................................    1.2728   21.45
110188................................................    1.3549   19.95
110189................................................    1.1692   18.84
110190................................................    1.0644   19.43
110191................................................    1.3076   19.11
110192................................................    1.4458   20.77
110193................................................    1.2436   18.78
110194................................................    0.8938   15.09
110195................................................    1.0992   10.52
110198................................................    1.2884   26.19
110200................................................    1.8855   17.14
110201................................................    1.5094   19.24
110203................................................    0.9314   20.30
110204................................................    0.8249   20.57
110205................................................    1.0578   26.12
110207................................................    1.0103   12.87
110208................................................    0.9617   14.89
110209................................................    0.7100   20.46
110209................................................    0.9560   17.78
110210................................................  ........   11.07
110211................................................    0.9611   21.82
110212................................................    1.0043   12.66
110213................................................  ........   13.20
110215................................................    1.0941  ......
110216................................................    2.1653  ......
110217................................................    2.8336  ......
120001*...............................................    1.8196   26.74
120002................................................    1.2037   24.38
120003................................................    1.1393   23.85
120004................................................    1.2630   24.05
120005................................................    1.2464   20.54
120006................................................    1.2735   23.72
120007................................................    1.7320   23.27
120009................................................    0.9632   19.02
120010*...............................................    1.8265   25.40
120011................................................    1.3581   33.55
120012................................................    0.8391   22.52
120014................................................    1.2760   24.05
120016................................................    1.0574   29.41
120018................................................  ........   25.61
120019................................................    1.3200   21.92
120019................................................    0.9579   14.67
120021................................................    0.9290   19.42
120022*...............................................    1.6850   17.94
120022*...............................................    1.6850   17.94
120022*...............................................    1.2230   15.96
120022*...............................................    1.2230   15.96
120024................................................    1.0727   22.28
120025................................................  ........   19.02
120026................................................    1.2644   23.22
120027................................................    1.4120   24.55
120028................................................    1.2471   22.84
130001................................................    0.9699   24.95
130002................................................    1.3252   16.19
130003................................................    1.3332   19.97
130005................................................    1.4390   20.19
130006................................................    1.8346   18.87
130007................................................    1.6708   19.84
130008................................................    0.9590   12.92
130009................................................    0.9294   18.30
130010................................................    0.8911   21.43
130011................................................    1.2864   19.08
130012................................................    0.9929   22.62
130013................................................    1.3310   19.22
130014................................................    1.3257   17.98
130015................................................    0.8827   15.27
130016................................................    1.0155   17.00
130017................................................    1.1012   16.88
130018................................................    1.6256   17.97
130019................................................    1.1193   17.23
130021................................................    0.9513   12.26
130022................................................    1.2324   19.50
130024................................................    1.1558   18.38
130025................................................    1.0970   15.27
130026................................................    1.1726   20.55
130027................................................    0.9243   20.70
130028................................................    1.2865   18.21
130029................................................    1.0707   19.87
130030................................................    0.8409   18.40
130031................................................    1.0121   17.65
130034................................................    1.0325   18.82
130034................................................    1.8152   18.40
130035................................................    1.1048   20.47
130036................................................    1.3946   13.79
130037................................................    1.3076   17.74
130043................................................    0.9605   16.07
130044................................................    0.9724   13.18
130045................................................    0.9752   16.47
130048................................................    0.9815   15.09
130049................................................    1.2325   20.05
130049................................................    1.5824   20.72
130056................................................    0.8528   15.66
130058................................................  ........   17.75
130060................................................    1.2796   20.85
130061................................................    1.2950   16.78
130061................................................    1.1145   17.32
130062................................................    0.6352   15.11
130063................................................    1.3116  ......
140001................................................    1.2277   15.44
140002................................................    1.2578   19.26
140003................................................    1.0026   16.59
140004................................................    1.1657   17.52
140005................................................    0.9695   10.87
140007................................................    1.4700   22.40
140007................................................    1.4015   21.54
140008................................................    1.4683   20.79
140010................................................    1.3722   24.43
140011................................................    1.2029   17.28
140012................................................    1.2779   20.11
140013................................................    1.5702   17.35
140014................................................    1.1734   20.76
140015................................................    1.2861   15.02
140018................................................    1.2551   20.84
140019................................................    1.1122   15.34
140025................................................    1.0822   16.43
140027................................................    1.2700   17.50
140027................................................    1.3076   18.47
140029................................................    1.3389   21.03
140030................................................    1.8231   22.44
140031................................................    1.2022   15.82
140032................................................    1.3343   17.34
140033................................................    1.2879   22.56
140034................................................    1.1842   18.96
140035................................................    0.9867   13.00
140036................................................    1.2425   17.04
140036................................................    1.1031   25.40

[[Page 24772]]

 
140037................................................    1.0365   12.50
140038................................................    1.1040   16.59
140040................................................    1.2582   16.25
140041................................................    1.1609   17.28
140042................................................    1.0170   15.61
140043................................................    1.1892   18.95
140045................................................    1.0337   20.65
140046................................................    1.3056   16.46
140047................................................    1.0942   15.68
140048................................................    1.3053   20.58
140049................................................    1.6549   18.31
140051................................................    1.5123   21.59
140052................................................    1.3010   19.60
140053................................................    2.0144   17.82
140054................................................    1.3340   26.64
140055................................................    1.0128   14.80
140058................................................    1.2361   17.27
140059................................................    1.1346   15.39
140061................................................    1.0918   15.96
140062................................................    1.2453   27.09
140063................................................    1.4369   22.39
140064................................................    1.3182   19.26
140065................................................    1.4623   22.75
140066................................................    1.1771   16.14
140068................................................    1.2906   18.87
140069................................................    1.0478   17.29
140070................................................    1.2528   19.30
140074................................................    1.0760   19.01
140075................................................    1.3678   22.51
140077................................................    1.2460   16.64
140079................................................    1.2649   24.08
140081................................................    1.0822   15.51
140082................................................    1.3677   22.62
140083................................................    1.2487   18.13
140084................................................    1.2530   19.97
140087................................................    1.3481   18.36
140088................................................    1.7061   24.19
140089................................................    1.2734   17.21
140090*...............................................    1.5241   22.31
140091................................................    1.9064   20.70
140093................................................    1.1684   19.15
140094................................................    1.3427   19.89
140097................................................    0.9518   16.90
140100................................................    1.3290   19.06
140101................................................    1.2258   26.09
140102................................................    1.0431   15.13
140103................................................    1.4249   17.86
140105................................................    1.2912   22.56
140107................................................    1.0115   12.76
140108................................................    1.3343   30.11
140109................................................    1.1455   15.47
140110................................................    1.2406   18.68
140112................................................    1.1571   16.24
140113................................................    1.5610   17.92
140114................................................    1.3330   20.11
140116................................................    1.2349   21.83
140117................................................    1.5621   19.72
140118................................................    1.7257   23.06
140119................................................    1.7733   26.00
140120................................................    1.3738   14.84
140121................................................    1.3603    9.53
140122................................................    1.5424   23.75
140125................................................    1.3486   17.10
140127................................................    1.4176   19.42
140128................................................    1.0297   17.67
140129................................................    1.1653   15.25
140130................................................    1.2502   23.77
140132................................................    1.4907   22.86
140133................................................    1.4008   19.88
140135................................................    1.2769   17.69
140137................................................    1.0216   16.51
140138................................................    1.0656   14.59
140139................................................    1.1054   16.58
140140................................................    1.1358   15.30
140141................................................    1.2625   15.18
140143................................................    1.0965   18.76
140144................................................    0.9972   20.02
140145................................................    1.1515   16.61
140146................................................    1.0726   23.74
140147................................................    1.2513   24.82
140148................................................    1.8284   19.50
140150................................................    1.6430   27.88
140151................................................    1.0622   19.30
140152................................................    1.1938   20.67
140155................................................    1.3261   17.52
140158................................................    1.3600   22.27
140160................................................    1.1729   17.88
140161................................................    1.2205   19.04
140162................................................    1.6991   18.42
140164................................................    1.4369   18.09
140165................................................    1.0868   15.42
140166................................................    1.1672   17.58
140167................................................    1.0995   16.17
140168................................................    1.1300   16.46
140170................................................    1.1305   14.14
140171................................................    0.9892   14.73
140172................................................    1.5894   20.07
140173................................................    0.8708   18.48
140174................................................    1.6068   19.89
140176................................................    1.2498   21.41
140177................................................    1.2111   18.17
140179................................................    1.3636   20.88
140180................................................    1.4489   23.25
140181................................................    1.4225   19.95
140182................................................    1.3614   20.48
140184................................................    1.2130   15.88
140185................................................    1.4938   17.36
140186................................................    1.3433   17.49
140187................................................    1.5860   17.72
140188................................................    0.9891   14.84
140189................................................    1.2539   19.08
140190................................................    1.0732   15.88
140191................................................    1.4402   24.74
140193................................................    1.0284   15.52
140197................................................    1.2538   17.98
140199................................................    1.0796   18.83
140200................................................    1.4770   21.65
140202................................................    1.3288   22.18
140203................................................    1.1563   20.78
140205................................................    0.9505   17.24
140206................................................    1.2043   20.39
140207................................................    1.2975   20.20
140208................................................    1.7189   23.94
140209................................................    1.6299   17.79
140210................................................    1.1139   12.66
140211................................................    1.2088   21.49
140213................................................    1.2799   26.20
140215................................................    0.9874   14.45
140217................................................    1.3239   22.26
140218................................................    0.9885   15.08
140220................................................    1.1219   16.73
140223................................................    1.5500   21.28
140224................................................    1.4304   22.99
140228................................................    1.6774   18.67
140230................................................    0.9389   16.60
140231................................................    1.5601   21.61
140233................................................    1.7821   18.39
140234................................................    1.2228   18.72
140236................................................    1.0843   13.13
140239................................................    1.7286   18.88
140240................................................    1.3944   21.83
140242................................................    1.6388   22.64
140246................................................    1.0612   12.82
140250................................................    1.3284   23.41
140251................................................    1.3090   20.54
140252................................................    1.4991   24.55
140253................................................    1.1636   16.74
140258................................................    1.5756   16.51
140271................................................    0.9729   15.36
140275................................................    1.2733   17.96
140276................................................    2.0648   25.46
140280................................................    1.3777   18.84
140285................................................    1.2740   14.71
140286................................................    1.1868   19.84
140288................................................    1.6194   20.59
140289................................................    1.3449   16.45
140290................................................    1.3397   25.88
140291................................................    1.3337   22.44
140292................................................    1.2935   22.71
140297................................................  ........   21.47
140300................................................    1.4604   23.46
150001................................................    1.1062   21.70
150002................................................    1.4495   18.66
150003................................................    1.7952   19.31
150004................................................    1.5197   19.70
150005................................................    1.1497   19.00
150006................................................    1.2614   20.04
150007................................................    1.1968   19.53
150009................................................    1.3657   17.53
150010................................................    1.3618   18.48
150011................................................    1.2157   19.19
150012................................................    1.6189   20.52
150013................................................    1.1006   16.00
150014................................................    1.6067   21.28
150015................................................    1.2931   22.06
150017................................................    1.9040   18.89
150018................................................    1.4570   18.62
150019................................................    1.0936   15.29
150020................................................    1.1517   14.46
150021................................................    1.6877  ......
150022................................................    1.0903   17.92
150023................................................    1.5766   18.71
150024................................................    1.3391   17.83

[[Page 24773]]

 
150025................................................    1.4398   18.15
150026................................................    1.2090   20.51
150029................................................    1.3389   21.74
150030................................................    1.2446   17.33
150031................................................    1.0811   18.01
150032................................................  ........   20.64
150033................................................    1.5737   21.69
150034................................................    1.4854   21.29
150035................................................    1.4921   19.82
150036................................................    0.9960   20.38
150037................................................    1.2881   17.79
150039................................................    1.0016   17.42
150042................................................    1.2830   17.12
150043................................................    1.1042   17.98
150044................................................    1.2625   17.64
150044................................................    1.2486   18.32
150045................................................    1.0927   17.04
150046................................................    1.3943   17.32
150047................................................    1.5983   20.57
150048................................................    1.1912   16.96
150049................................................    1.2166   16.85
150050................................................    1.1659   17.14
150051................................................    1.5099   18.20
150052................................................    1.0909   15.36
150053................................................    0.9867   18.75
150054................................................    1.1350   17.33
150054................................................    1.0816   15.23
150056................................................    1.8874   23.30
150057................................................    2.2401   16.86
150058................................................    1.7056   20.94
150059................................................    1.3586   20.80
150060................................................    1.1860   16.01
150061................................................    1.2108   17.21
150062................................................    1.1076   18.41
150063................................................    1.0891   21.09
150064................................................    1.1810   16.88
150065................................................    1.1695   19.01
150066................................................    1.0226   14.60
150067................................................    1.1260   17.08
150069................................................    1.2233   17.39
150070................................................    0.9579   17.20
150071................................................    1.0955   14.73
150072................................................    1.1997   16.11
150073................................................    1.0623   19.03
150074................................................    1.6321   18.80
150075................................................    1.1204   14.98
150076................................................    1.1815   22.34
150077................................................    0.8126   17.58
150078................................................    1.0515   19.01
150079................................................    1.1737   15.45
150082................................................    1.5261   17.88
150084................................................    1.9911   22.92
150086................................................    1.2506   17.34
150088................................................    1.3443   19.45
150089................................................    1.4584   22.79
150090................................................    1.3311   19.06
150091................................................    1.0358   19.89
150092................................................    1.0071   15.92
150094................................................    0.9754   18.34
150095................................................    1.0873   17.12
150096................................................    1.0067   20.03
150097................................................    1.0922   18.31
150098................................................    1.1583   14.30
150099................................................  ........   19.05
150100................................................    1.6560   17.45
150101................................................    1.0932   17.56
150102................................................    1.0786   11.50
150103................................................    0.9709   17.31
150104................................................    1.1262   17.26
150105................................................    1.3363   19.17
150106................................................    1.0512   18.91
150109................................................    1.3950   18.23
150109................................................    0.9960   14.44
150110................................................    0.9833   18.58
150111................................................    1.1623   16.17
150112................................................    1.2432   19.82
150113................................................    1.2363   19.30
150114................................................    0.9759   16.96
150115................................................    1.3380   17.06
150122................................................    1.1564   19.35
150123................................................    1.1155   15.16
150124................................................    1.0883   15.07
150125................................................    1.4626   20.31
150126................................................    1.4875   20.33
150126................................................    1.0382   15.85
150127................................................    1.0281   22.81
150129................................................    1.1879   23.39
150130................................................    1.3446   16.19
150132................................................    1.4200   19.37
150132................................................    1.4200   19.37
150133................................................    1.1908   16.49
150134................................................    1.1980   17.06
150136................................................    0.9556   19.28
160001................................................    1.2605   19.03
160002................................................    1.0936   15.37
160003................................................    0.9983   15.77
160007................................................    1.0218   15.66
160008................................................    1.1414   14.97
160009................................................    1.2218   16.09
160012................................................    1.0466   16.54
160013................................................    1.1370   17.06
160014................................................    1.0250   15.09
160014................................................    1.0321   14.26
160016................................................    1.1679   18.37
160018................................................    0.9632   14.16
160020................................................    1.0694   13.91
160021................................................    1.1170   15.49
160023................................................    1.0888   14.20
160024................................................    1.6094   18.95
160026................................................    1.0266   18.66
160027................................................    1.0851   15.74
160028................................................    1.2340   20.44
160029................................................    1.5289   20.40
160030................................................    1.3882   17.99
160031................................................    1.1181   15.28
160032................................................    1.1544   16.18
160033................................................    1.9173   18.37
160034................................................    1.1493   14.51
160035................................................    0.8438   15.92
160036................................................    1.0544   18.91
160037................................................    1.0584   18.40
160039................................................    1.0389   17.63
160040................................................    1.2661   16.83
160041................................................    1.0648   15.58
160043................................................    0.9893   15.63
160044................................................    1.2182   16.04
160045................................................    1.8186   20.12
160046................................................    1.0239   14.77
160047................................................    1.3703   16.93
160048................................................    1.2473   13.14
160049................................................    0.9262   13.36
160050................................................    1.0709   16.42
160051................................................    0.8978   14.27
160052................................................    0.9936   17.55
160054................................................    1.0281   15.71
160055................................................    0.9846   14.06
160056................................................    1.0679   15.38
160057................................................    1.2435   17.41
160058................................................    1.8383   20.34
160060................................................    1.0430   15.95
160061................................................    1.0815   17.57
160063................................................    1.1620   16.30
160064................................................    1.5348   19.94
160065................................................    1.0510   16.51
160066................................................    1.1016   16.26
160067................................................    1.4226   17.85
160068................................................    1.0237   15.85
160069................................................    1.5362   18.49
160070................................................    0.9937   15.66
160072................................................    1.0339   14.19
160073................................................    0.9954   15.05
160075................................................    1.0796   17.89
160076................................................    1.0993   17.31
160077................................................    1.1152   11.40
160079................................................    1.4125   17.71
160079................................................    1.4017   16.15
160081................................................    1.1531   16.51
160082................................................    1.9254   18.80
160083................................................    1.6684   18.41
160085................................................    1.0030   18.55
160086................................................    0.9493   16.46
160088................................................    1.1546   17.53
160089................................................    1.1915   16.74
160090................................................    1.0124   16.60
160091................................................    1.0383   12.19
160092................................................    1.0124   15.80
160093................................................    1.0155   15.95
160094................................................    1.1043   16.56
160097................................................    1.0774   15.21
160098................................................    0.9397   15.54
160099................................................    0.9650   13.79
160101................................................    1.0852   17.87
160102................................................    1.3435   18.36
160103................................................    0.9416   17.15
160104................................................    1.3010   19.76
160106................................................    1.1089   16.66
160107................................................    1.1508   16.56
160108................................................    1.0237   15.42
160109................................................    1.0167   16.49
160110................................................    1.5117   19.93
160111................................................    0.9983   13.17
160112................................................    1.3773   16.28
160113................................................    1.0930   14.58

[[Page 24774]]

 
160114................................................    0.9786   14.95
160115................................................    0.9774   15.76
160116................................................    1.1196   16.69
160117................................................    1.4123   17.29
160118................................................    0.9961   15.84
160120................................................    0.9938   12.56
160122................................................    1.1131   18.52
160124................................................    1.2998   17.16
160126................................................    0.9654   17.74
160129................................................    0.9727   15.89
160130................................................    1.1286   15.45
160131................................................    1.0444   14.69
160134................................................    0.9506   13.32
160135................................................    1.0170   16.33
160138................................................    1.0149   15.71
160140................................................    1.1324   18.80
160142................................................    1.0194   16.14
160143................................................    1.1242   15.92
160145................................................    1.0697   15.17
160146................................................    1.4409   13.50
160147................................................    1.2762   18.39
160151................................................    1.0545   15.74
160152................................................    0.9384   15.22
160153................................................    1.7613   19.69
170001................................................    1.2074   17.52
170004................................................    1.0753   13.06
170006................................................    1.1961   19.31
170008................................................    1.0034   13.90
170009................................................    1.1438   19.59
170010................................................    1.3587   17.90
170012................................................    1.4141   16.76
170013................................................    1.2829   17.89
170014................................................    1.0333   17.34
170015................................................    0.9812   16.34
170016................................................    1.7067   18.60
170017................................................    1.2014   17.87
170018................................................    1.1012   14.36
170019................................................    1.2360   16.56
170022................................................    1.0526   17.85
170023................................................    1.4684   19.36
170024................................................    1.0663   13.06
170025................................................    1.1917   16.37
170026................................................    1.0818   13.89
170027................................................    1.3172   16.39
170030................................................    1.0591   15.24
170031................................................    0.8922   13.47
170032................................................    1.0128   14.48
170033................................................    1.4150   16.05
170034................................................    1.0335   15.02
170035................................................    0.8966   15.62
170036................................................  ........   14.17
170038................................................    0.8998   14.21
170039................................................    1.0943   14.30
170040................................................    1.5837   17.97
170041................................................    1.0521   11.47
170044................................................    0.9951   14.78
170045................................................    1.0889   12.11
170049................................................    1.3499   18.64
170051................................................    0.9890   14.16
170052................................................    1.0435   14.62
170053................................................    0.9336    9.03
170054................................................    1.0324   12.77
170055................................................    0.9801   14.99
170056................................................    0.8854   14.87
170057................................................  ........   15.09
170058................................................    1.1572   18.17
170060................................................    1.0218   17.23
170061................................................    1.1583   14.14
170063................................................    0.8974   11.49
170064................................................  ........   12.42
170066................................................    0.9451   14.48
170067................................................    0.9987   12.71
170068................................................    1.2647   15.82
170070................................................    1.0543   13.37
170072................................................    0.9012   13.34
170073................................................    1.0417   16.47
170074................................................    1.2016   14.40
170075................................................    0.9266   11.26
170076................................................    1.0220   13.58
170077................................................    0.9136   13.11
170079................................................    0.9666   14.21
170080................................................    0.9657   12.20
170081................................................    0.9118   12.51
170082................................................    0.9428   12.39
170084................................................    0.8978   12.16
170085................................................    0.8828   14.51
170086................................................    1.6770   19.85
170088................................................    0.9319   11.37
170089................................................    0.9738   18.08
170090................................................    0.9616   11.27
170092................................................  ........   12.85
170093................................................    0.8913   12.79
170094................................................    0.9571   17.71
170095................................................    1.0123   15.75
170097................................................    0.9071   15.66
170098................................................    1.1366   14.10
170099................................................    1.1582   13.55
170100................................................  ........   14.47
170101................................................    0.9709   13.16
170102................................................    0.9675   13.35
170103................................................    1.3238   16.66
170104................................................    1.4841   19.76
170105................................................    1.0598   15.93
170106................................................    0.9341   14.68
170109................................................    0.9347   16.87
170110................................................    0.9851   15.55
170112................................................    1.1373   13.39
170113................................................    1.0737   13.25
170114................................................    0.9511   14.51
170115................................................    0.9965   13.03
170116................................................    1.0601   15.76
170117................................................    0.9782   15.28
170119................................................    0.9547   13.97
170120................................................    1.2724   15.91
170122................................................    1.7580   18.62
170124................................................    0.9913   10.21
170126................................................    0.9316   12.13
170128................................................    0.9622   14.99
170131................................................  ........   13.10
170133................................................    1.1289   16.90
170134................................................    0.8746   12.90
170137................................................    1.1809   17.42
170139................................................    0.9898   13.28
170142................................................    1.3140   17.32
170143................................................    1.1148   15.88
170144................................................    1.5078   16.09
170145................................................    1.1143   16.75
170146................................................    1.4429   19.97
170147................................................    1.1965   16.28
170148................................................    1.3707   17.25
170150................................................    1.1488   15.43
170151................................................    0.9381   13.37
170152................................................    1.0039   13.68
170160................................................    0.9959   13.31
170164................................................    0.9827   15.25
170166................................................    1.1079   17.57
170171................................................    1.0545   13.81
170175................................................    1.3046   16.60
170176................................................    1.6707   20.32
170182................................................    1.4297   14.20
170183................................................    1.9808   19.09
170184................................................  ........   27.01
180001................................................    1.3847   19.52
180002................................................    1.0822   18.13
180004................................................    1.1128   15.99
180005................................................    1.1971   20.63
180006................................................    0.9090   11.23
180007................................................    1.4645   17.20
180009................................................    1.3630   20.81
180010................................................    1.9327   17.55
180011................................................    1.3163   16.93
180012................................................    1.4400   18.74
180012................................................    0.8766   13.61
180013................................................    1.4541   17.35
180014................................................    1.6943   19.54
180016................................................    1.3332   18.84
180017................................................    1.3056   15.17
180018................................................    1.2982   18.92
180019................................................    1.1910   16.76
180020................................................    1.1105   17.78
180021................................................    1.0495   15.16
180023................................................    0.9502   15.22
180024................................................    1.4092   15.33
180025................................................    1.2023   17.17
180026................................................    1.2026   14.16
180027................................................    1.2506   14.89
180028................................................    1.0909   19.35
180030................................................    1.1726   17.02
180031................................................    1.1189   13.79
180032................................................    1.0597   16.09
180033................................................    1.0978   13.77
180034................................................    1.0888   17.32
180035................................................    1.6441   19.45
180036................................................    1.1569   19.12
180037................................................    1.3126   19.85
180038................................................    1.4604   16.19
180040*...............................................    1.9257   19.33
180041................................................    1.1796   15.17
180042................................................    1.1689   16.29
180043................................................    1.1236   16.76
180044................................................    1.1974   17.82
180045................................................    1.4022   17.73
180046................................................    1.0438   17.91

[[Page 24775]]

 
180047................................................    0.9987   15.04
180048................................................    1.2470   19.58
180049................................................    1.3488   16.08
180050................................................    1.2186   18.48
180051................................................    1.3835   15.68
180053................................................    1.0555   14.63
180054................................................    1.0903   16.39
180055................................................    1.2207   14.64
180056................................................    1.1035   16.62
180058................................................    1.0460   14.36
180059................................................    0.8719   14.26
180060................................................  ........    7.21
180063................................................    1.0712   11.91
180064................................................    1.1788   14.49
180065................................................    1.0766   14.41
180066................................................    1.0776   18.56
180067................................................    1.8904   18.53
180069................................................    1.1224   17.30
180070................................................    1.1057   13.84
180072................................................    1.1158   17.85
180075................................................  ........   15.07
180078................................................    1.0782   19.16
180079................................................    1.1805   13.41
180080................................................    1.0799   16.48
180087................................................    1.2301   14.97
180088................................................    1.6075   21.86
180088................................................    1.4138   21.69
180092................................................    1.2224   16.31
180093................................................    1.4101   16.70
180094................................................    1.0268   12.51
180095................................................    1.1318   13.40
180099................................................    1.0392   13.29
180101................................................    1.1741   19.56
180102................................................    1.4371   17.88
180103................................................    2.3154   19.79
180104................................................    1.5469   19.20
180105................................................    0.8827   14.00
180108................................................    0.8257   14.62
180115................................................    0.9594   17.11
180116................................................    1.2331   16.94
180117................................................    1.1147   18.38
180118................................................    0.9643   12.15
180120................................................    1.0167   17.81
180121................................................    1.1698   14.51
180122................................................    1.0642   16.97
180123................................................    1.3539   18.53
180124................................................    1.3287   18.41
180125................................................    1.1259   19.73
180126................................................    1.1152   12.40
180127................................................    1.2902   17.35
180128................................................    1.0669   17.05
180129................................................    0.9818   17.86
180130................................................    1.4359   19.11
180132................................................    1.2721   17.26
180133................................................    1.3322   21.66
180134................................................    1.0885   13.63
180136................................................    1.8166   17.71
180138................................................    1.1992   18.51
180139................................................    1.0560   18.77
180140................................................    0.9768   20.40
180141................................................    1.8575   19.04
180141................................................    1.1972   12.59
180142................................................    1.7800  ......
190001................................................    0.8866   16.91
190002................................................    1.6874   18.84
190003................................................    1.3295   22.15
190004................................................    1.4230   17.54
190005................................................    1.5174   16.71
190006................................................    1.4666   17.73
190007................................................    1.0552   13.60
190008................................................    1.6186   16.89
190009................................................    1.2882   14.21
190010................................................    1.2081   17.02
190011................................................    1.1424   15.17
190013................................................    1.3002   16.57
190014................................................    1.1875   17.02
190014................................................    0.9519   12.03
190015................................................    1.2666   17.44
190017................................................    1.3398   15.79
190018................................................    1.1056   16.98
190019................................................    1.7887   17.40
190020................................................    1.1956   17.31
190025................................................    1.3076   16.07
190026................................................    1.5552   17.21
190027................................................    1.5165   16.19
190029................................................    1.1492   17.11
190033................................................    0.9722   10.74
190034................................................    1.1705   16.68
190036*...............................................    1.6847   19.96
190037................................................    0.9649   12.02
190039................................................    1.4112   17.17
190040................................................    1.3287   20.32
190041................................................    1.6088   17.90
190043................................................    1.0328   12.57
190044................................................    1.1661   17.20
190046................................................    1.4251   19.35
190048................................................    1.1957   16.34
190049................................................    0.9392   16.42
190050................................................    1.0736   15.38
190053................................................    1.1486   12.50
190054................................................    1.2942   16.47
190059................................................    0.8905   15.84
190060................................................    1.3931   18.37
190064................................................    1.5246   19.90
190065................................................    1.4989   19.39
190071................................................    0.8369   13.59
190077................................................    0.8858   12.83
190078................................................    1.1110   13.50
190079................................................    1.3557   17.29
190081................................................    0.8865   12.02
190083................................................    1.0658   16.14
190086................................................    1.3284   14.93
190088................................................    1.2141   19.63
190089................................................    1.1099   12.79
190090................................................    1.0416   16.56
190092................................................  ........   18.07
190095................................................    0.9939   15.73
190098................................................    1.5397   19.22
190099................................................    1.1795   18.92
190102................................................    1.6352   15.80
190103................................................    0.9074   15.57
190106................................................    1.1251   17.75
190109................................................    1.2494   14.53
190110................................................    0.9774   11.08
190111*...............................................    1.5870   20.05
190112................................................    1.6970   19.21
190113................................................    1.3935   18.99
190114................................................    1.0147   12.91
190115................................................    1.2775   20.49
190118................................................    0.9963   12.95
190120................................................    0.9962   13.69
190122*...............................................    1.2965   14.84
190124................................................    1.6278   22.38
190125................................................    1.4991   18.63
190128................................................    1.1982   19.71
190130................................................    0.9925   12.43
190131................................................    1.2614   19.60
190133................................................    1.0847   13.48
190134................................................    1.0023   12.68
190135................................................    1.4331   20.93
190136................................................    0.9971   11.33
190138................................................  ........   22.71
190142................................................    0.9232   14.98
190144................................................    1.1836   16.84
190145................................................    0.9751   13.99
190146................................................    1.5262   20.09
190147................................................    0.9769   14.32
190148................................................    0.9448   14.02
190149................................................    0.9966   15.19
190151................................................    1.0782   11.92
190152................................................    1.5096   20.40
190155................................................  ........   11.08
190156................................................    0.9565   12.48
190158................................................    1.2674   19.62
190160................................................    1.2596   18.47
190161................................................    1.0853   12.58
190162................................................    1.2971   17.97
190164................................................    1.1850   16.33
190167................................................    1.1284   16.29
190170................................................    0.9050   13.58
190173................................................    1.3272   18.83
190175................................................    1.4238   20.69
190176................................................    1.6021   16.67
190177................................................    1.7143   20.32
190178................................................    0.9276   10.49
190182................................................    1.3004   20.03
190183................................................    1.1923   16.11
190184................................................    0.9965   14.86
190185................................................    1.3089   19.37
190186................................................    0.9403   16.36
190189................................................  ........   26.54
190190................................................    0.9141   18.68
190191................................................    1.1473   18.14
190196................................................    0.9516   14.87
190197................................................    1.1818   17.92
190199................................................    1.0597   12.58
190200................................................    1.4899   19.41
190201................................................    1.0997   19.14
190202................................................    1.1256   17.90
190203................................................    1.4061   21.43
190204................................................    1.4939   21.21
190205................................................    1.9208   18.10
190206................................................    1.6291   19.82

[[Page 24776]]

 
190207................................................    1.2579   17.67
190208................................................    0.8059   14.61
190218................................................    1.0606   18.16
190223................................................  ........   19.26
190227................................................    1.0049   12.11
190231................................................    1.5614   16.89
190235................................................  ........   16.80
190236................................................    1.4216   22.18
190237................................................    2.4934  ......
190238................................................    1.6330  ......
190239................................................    1.1544  ......
190240................................................    0.9642  ......
200001................................................    1.3472   17.49
200002................................................    1.1142   18.77
200003................................................    1.0982   16.74
200006................................................    1.0868   16.34
200007................................................    1.0197   17.62
200008................................................    1.2216   20.50
200009................................................    1.8812   20.62
200012................................................    1.1783   17.01
200013................................................    1.1139   16.49
200015................................................  ........   20.11
200016................................................    1.0407   17.66
200017................................................  ........   19.70
200018................................................    1.2072   17.24
200019................................................    1.2519   18.48
200020................................................    1.1541   20.60
200021................................................    1.1958   18.88
200023................................................    0.8402   14.92
200024................................................    1.4798   18.65
200025................................................    1.2493   19.07
200026................................................    0.9915   17.28
200027................................................    1.2369   18.28
200028................................................    0.9205   16.93
200031................................................    1.2258   15.90
200032................................................    1.3282   17.92
200033................................................    1.7813   21.40
200034................................................    1.2763   19.13
200037................................................    1.2272   18.24
200038................................................    1.1414   19.21
200039................................................    1.2559   20.29
200040................................................    1.1170   19.13
200041................................................    1.1252   17.66
200043................................................    0.8031   16.54
200050................................................    1.2072   18.08
200051................................................    0.9896   19.48
200052................................................    0.9958   15.12
200055................................................    1.0875   17.13
200062................................................    0.9507   16.51
200063................................................    1.2430   19.67
200066................................................    1.1419   16.32
210001................................................    1.4438   18.73
210002................................................    2.0439   22.84
210003................................................    1.6821   25.37
210004................................................    1.3607   23.44
210005................................................    1.2933   19.62
210006................................................    1.1140   17.77
210007................................................    1.8016   21.54
210008................................................    1.3069   19.50
210009................................................    1.8548   21.81
210010................................................    1.1378   26.83
210011................................................    1.3632   21.24
210012................................................    1.6193   23.43
210013................................................    1.3591   18.85
210015................................................    1.3063   16.69
210016................................................    1.8523   22.01
210017................................................    1.2499   17.17
210018................................................    1.2636   21.41
210019................................................    1.6163   19.09
210022................................................    1.4875   21.32
210023................................................    1.4502   21.80
210024................................................    1.6941   19.56
210025................................................    1.3279   19.57
210026................................................    1.3217   11.64
210027................................................    1.2802   18.49
210028................................................    1.1693   18.86
210029................................................    1.2777   21.43
210030................................................    1.2555   21.02
210031................................................    1.3110   15.59
210032................................................    1.1730   18.50
210033................................................    1.2407   19.91
210034................................................    1.3165   16.12
210035................................................    1.3414   20.61
210037................................................    1.2643   18.74
210038................................................    1.4181   23.26
210039................................................    1.1915   20.73
210040................................................    1.3180   25.08
210043................................................    1.2815   40.60
210044................................................    1.3645   22.24
210045................................................    1.0892    9.88
210048................................................    1.2893   22.39
210049................................................    1.1702   17.67
210051................................................    1.4024   20.76
210054................................................    1.3673   23.51
210055................................................    1.3658   20.09
210056................................................    1.3928   20.94
210057................................................    1.3587   22.57
210058................................................    1.5007   21.37
210059................................................    1.1847   23.13
210060................................................    1.2753  ......
210061................................................    1.1313   20.02
220001................................................    1.2879   26.32
220002................................................    1.4678   22.58
220003................................................    1.1104   19.14
220004................................................  ........   20.01
220006................................................    1.3867   22.04
220008................................................    1.2973   21.89
220010................................................    1.3481   22.06
220011................................................    1.0947   23.85
220012................................................    1.3117   28.24
220015................................................    1.1691   21.73
220016................................................    1.3445   21.30
220017................................................    1.3512   24.90
220019................................................    1.1561   19.13
220020................................................    1.2448   20.00
220023................................................    0.6351   18.76
220024................................................    1.2167   21.59
220025................................................    1.1442   19.94
220028*...............................................    1.4573   22.18
220029................................................    1.1595   21.19
220030................................................    1.1073   14.54
220031................................................    1.9074   22.82
220033................................................    1.2602   20.83
220035................................................    1.3063   22.00
220036................................................    1.6289   24.16
220038................................................    1.3130   23.31
220041................................................    1.1893   22.83
220042................................................    1.2662   25.28
220046................................................    1.3199   23.90
220049................................................    1.2823   17.27
220050................................................    1.1667   20.83
220051................................................    1.1784   20.48
220052................................................    1.2993   23.01
220053................................................    1.1637   21.27
220055................................................    1.2850   21.57
220055................................................    1.2703   19.76
220057................................................    1.3594   21.93
220060................................................    1.2295   26.98
220062................................................    0.5638   20.06
220063................................................    1.2671   20.91
220064................................................    1.2833   17.90
220065................................................    1.3711   20.10
220066................................................    1.3459   19.43
220067................................................    1.2869   25.74
220068................................................  ........    6.45
220070................................................    1.2165   16.72
220071................................................    1.9239   24.67
220073................................................    1.3015   26.08
220074................................................    1.3358   15.22
220075................................................    1.7972   19.96
220076................................................    1.2501   20.83
220077................................................    1.8283   24.48
220079................................................    1.0997   21.01
220080................................................    1.3044   17.16
220081................................................    0.9163   25.77
220082................................................    1.2658   20.02
220083................................................    1.1887   20.93
220084................................................    1.2481   24.66
220086................................................    1.7933   30.00
220088................................................    1.6455   22.71
220089................................................    1.2583   21.81
220090................................................    1.2260   21.42
220092................................................    1.1838   17.04
220094................................................  ........   21.99
220095................................................    1.1894   21.45
220098................................................    1.3175   20.34
220098................................................    1.2347   20.43
220100................................................    1.3674   25.39
220101................................................    1.4449   24.15
220104................................................    1.4666   26.76
220105................................................    1.2706   21.69
220106................................................    1.2167   24.34
220107................................................  ........   20.14
220108................................................    1.1915   22.52
220110................................................    2.1015   29.15
220111................................................    1.2455   23.07
220116................................................    1.9143   27.64
220118................................................  ........   30.02
220119................................................    1.2616   22.78
220123................................................    1.0317   17.74
220126................................................    1.2498   20.96
220128................................................  ........   21.92
220133................................................    0.7187   24.34

[[Page 24777]]

 
220135................................................    1.2824   25.08
220153................................................    1.0071   15.97
220154................................................    0.9023   14.84
220162................................................    1.4831  ......
220163................................................    2.0302   27.35
220171................................................    1.6811   23.43
230001................................................    1.1539   19.20
230002................................................    1.2731   21.91
230003................................................    1.1409   19.61
230004................................................    1.6874   22.42
230005................................................    1.2532   19.40
230006................................................    1.0501   18.47
230007................................................  ........   19.43
230012................................................    0.9650   18.67
230012................................................    1.9036   23.94
230013................................................    1.3748   20.12
230015................................................    1.0768   20.43
230017................................................    1.6133   20.40
230019................................................    1.5299   19.05
230020................................................    1.7464   21.04
230021................................................    1.5000   18.57
230021................................................    1.1691   18.89
230024................................................    1.4282   27.96
230027................................................    1.0357   18.03
230029................................................    1.5743   21.12
230030................................................    1.3405   17.29
230031................................................    1.4291   17.00
230032*...............................................    1.7456   20.08
230034................................................    1.2673   17.23
230035................................................    1.0750   17.56
230035................................................    1.6288   23.05
230036................................................    1.2559   21.76
230037................................................    1.1615   19.07
230038................................................    1.7574   23.40
230040................................................    1.1346   20.39
230041................................................    1.2536   19.03
230042................................................    1.2327   19.49
230046................................................    1.9231   25.91
230047................................................    1.3568   20.64
230053................................................    1.5887   22.22
230054................................................    1.8405   19.54
230055................................................    1.1698   19.84
230056................................................    0.8968   16.41
230058................................................    1.1023   18.23
230059................................................    1.4582   18.96
230060................................................    1.3307   17.87
230062................................................    0.9642   16.30
230063................................................    1.2587   20.22
230065................................................    1.3139   21.28
230066................................................    1.3669   21.51
230069................................................    1.1982   22.49
230070................................................    1.6490   20.06
230071................................................    1.1156   22.16
230075................................................    1.5045   19.43
230076................................................    1.4082   23.82
230077................................................    2.0553   20.39
230078................................................    1.1150   16.25
230078................................................    1.1358   15.56
230080................................................    1.2452   18.91
230081................................................    1.2102   18.04
230082................................................    1.1207   17.74
230085................................................    1.2359   17.54
230086................................................    0.9482   16.98
230087................................................    1.0847   15.77
230089................................................    1.2859   21.39
230092................................................    1.3590   18.96
230093................................................    1.2299   19.99
230095................................................    1.1731   16.78
230096................................................    1.1072   22.56
230097................................................    1.6199   20.10
230099................................................    1.1231   20.25
230100................................................    1.1427   13.11
230101................................................    1.0672   18.61
230103................................................    1.0527   20.76
230104................................................    1.5554   23.47
230105................................................    1.7966   20.88
230106................................................    1.1826   18.35
230107................................................    0.9423   14.67
230108................................................    1.2079   17.42
230110................................................    1.3163   17.65
230113................................................    0.8490   11.17
230115................................................    1.0580   16.87
230116................................................    0.8654   16.36
230118................................................    1.1403   21.71
230119................................................    1.3594   23.96
230120................................................    1.1248   19.64
230121................................................    1.2279   19.37
230122................................................    1.3518   18.09
230125................................................  ........   15.35
230128................................................    1.4028   23.58
230130................................................    1.6932   22.52
230132................................................    1.3334   26.17
230133................................................    1.2298   17.57
230134................................................  ........   15.32
230135................................................    1.2320   22.74
230137................................................  ........   18.34
230142................................................    1.2837   20.04
230143................................................    1.2803   16.45
230144................................................    1.1223   21.00
230145................................................    1.1219   16.60
230146................................................    1.2603   18.63
230147................................................    1.4098   20.40
230149................................................    1.1317   14.17
230151................................................    1.4140   20.89
230153................................................    1.0658   17.33
230154................................................    0.8898   14.58
230155................................................    1.0298   16.99
230156................................................    1.7470   23.28
230157................................................    1.1677   19.72
230159................................................    1.0227   18.61
230162................................................    0.9532   17.77
230165................................................    1.9359   23.23
230167................................................    1.7502   20.32
230169................................................    1.3613   22.75
230171................................................    1.0817   14.96
230172................................................    1.1873   20.22
230174................................................    1.3724   20.85
230175................................................    2.3801   21.81
230176................................................    1.2168   21.86
230178................................................    0.9485   16.08
230180................................................    1.1229   15.48
230184................................................    1.2534   17.29
230188................................................    1.1197   15.56
230189................................................    0.9464   15.91
230190................................................    0.8801   23.71
230191................................................    0.9321   17.12
230193................................................    1.3023   20.18
230195................................................    1.3569   22.37
230197................................................    1.4043   21.62
230199................................................    1.0833   18.40
230201................................................    1.2527   15.32
230204................................................    1.3728   21.89
230205................................................    0.9894   13.89
230207................................................    1.2522   20.46
230208................................................    1.3046   17.15
230211................................................    0.9159   17.51
230212................................................    1.0559   22.18
230213................................................    0.9300   15.32
230216................................................    1.5737   19.59
230217................................................    1.2657   20.95
230219................................................    0.8632   20.70
230221*...............................................  ........   21.55
230222................................................    1.3904   20.79
230223................................................    1.2692   21.50
230227................................................    1.4208   21.21
230230................................................    1.5877   22.53
230232................................................  ........   12.64
230235................................................    1.0880   15.95
230236*...............................................    1.3245   23.22
230239................................................    1.1705   19.23
230241................................................    1.1942   18.85
230244................................................    1.4114   21.08
230253................................................    0.9600   21.95
230254................................................    1.2928   21.28
230257................................................    0.9141   20.47
230259................................................    1.1398   21.15
230264................................................    1.6552   15.18
230269................................................    1.3095   22.81
230270................................................    1.2029   20.08
230273................................................    1.5232   23.40
230275................................................    0.5244   17.60
230276................................................    0.5657   18.55
230277................................................    1.2488   22.50
230278................................................  ........   16.66
230279................................................    0.6538   16.04
230280................................................    1.0995   14.22
230283................................................    2.2297  ......
240001................................................    1.5271   22.84
240002................................................    1.7570   23.02
240004*...............................................    1.5922   16.53
240005................................................    0.8861   16.98
240006................................................    1.1644   27.11
240007................................................    1.0673   16.98
240008................................................    1.1466   21.81
240009................................................    0.9419   16.69
240010................................................    1.9784   22.62
240011................................................    1.1515   18.96
240013................................................    1.2854   18.97
240014................................................    1.0968   21.86
240016................................................    1.3901   19.86
240017................................................    1.1526   17.23
240018................................................    1.2687   19.07
240019................................................    1.1859   21.13

[[Page 24778]]

 
240020................................................    1.1172   19.57
240021................................................    0.9884   17.40
240022................................................    1.1049   19.16
240023................................................    0.9789   20.39
240025................................................    1.0980   17.25
240027................................................    1.0711   16.25
240028................................................    1.1581   19.38
240029................................................    1.1501   17.99
240030................................................    1.2802   18.44
240031................................................    0.9276   18.07
240036................................................    1.5871   20.12
240037................................................    1.0154   18.46
240038................................................    1.5017   26.35
240040................................................    1.2684   19.90
240041................................................    1.1728   19.21
240043................................................    1.2228   17.31
240044................................................    1.1357   18.92
240045................................................    1.1584   20.99
240047*...............................................    1.5726   21.86
240048................................................  ........   23.31
240049................................................  ........   22.13
240050................................................    1.2114   24.50
240051................................................    0.9654   18.23
240052................................................    1.3024   19.22
240053................................................    1.4855   21.29
240056................................................    1.2541   22.29
240057................................................    1.8364   23.24
240058................................................    0.9292   14.91
240059................................................    1.0456   21.96
240061................................................    1.7666   24.44
240063................................................    1.4484   23.54
240064................................................    1.3259   20.76
240065................................................    1.1496   12.55
240066................................................    1.2838   22.05
240069................................................    1.1917   19.18
240071................................................    1.1069   19.19
240072................................................    1.0236   18.00
240073................................................    0.9003   15.63
240075................................................    1.2015   21.19
240076................................................    1.0725   21.07
240077................................................    0.9002   14.95
240078................................................    1.5426   22.71
240079................................................    0.9545   17.82
240080*...............................................    1.6152   23.73
240082................................................    1.1235   18.03
240083................................................    1.2898   19.29
240084................................................    1.3236   19.61
240085................................................    1.0306   18.02
240086................................................    1.0482   15.33
240087................................................    1.1607   17.06
240088................................................    1.4006   21.02
240089................................................    0.9225   18.42
240090................................................    1.1288   18.05
240093................................................    1.2970   18.62
240094................................................    0.9639   20.57
240096................................................    0.9900   18.34
240096................................................    1.2640   23.33
240097................................................    1.1145   23.62
240098................................................    0.9270   20.60
240099................................................    1.0725   14.36
240099................................................    1.6247   18.12
240100................................................    1.2887   19.19
240101................................................    1.2099   17.75
240102................................................    0.9273   15.56
240103................................................    1.2125   16.88
240103................................................    1.2125   16.88
240103................................................    1.2687   16.60
240104................................................    1.1691   24.02
240105................................................  ........   14.79
240106................................................    1.3931   25.05
240107................................................    0.9756   19.03
240108................................................    0.9778   16.46
240109................................................    0.9814   13.15
240110................................................    0.9389   17.28
240111................................................    0.9906   17.04
240112................................................    0.9763   15.31
240114................................................    0.9379   15.49
240115................................................    1.6118   22.16
240116................................................    0.9248   15.18
240117................................................    1.1441   17.57
240119................................................    0.8604   22.50
240121................................................    0.9071   21.37
240122................................................    1.0827   18.04
240123................................................    1.0205   15.60
240124................................................    0.9613   19.05
240125................................................    0.9698   13.15
240127................................................    1.0079   14.77
240128................................................    1.1138   16.08
240129................................................    0.9949   15.42
240130................................................    0.9322   15.65
240132................................................    1.2724   24.50
240133................................................    1.2207   18.52
240135................................................    0.9181   13.60
240137................................................    1.1748   19.18
240138................................................    0.9322   13.74
240139................................................    0.9615   17.02
240141................................................    1.1553   21.99
240142................................................    1.0125   20.61
240142................................................    0.9881   16.75
240143................................................    0.9663   14.28
240144................................................    1.0451   15.87
240145................................................    0.9125   15.00
240145................................................    1.5277   15.71
240146*...............................................    0.9085   16.79
240148................................................    1.0240   11.48
240150................................................    0.8795   12.83
240152................................................    1.0247   20.20
240153................................................    1.0015   15.61
240154................................................    1.0211   17.06
240155................................................    0.9166   20.42
240157................................................    1.0227   14.69
240160................................................    1.0601   16.60
240161................................................    1.0376   15.42
240163................................................    0.9706   17.87
240166................................................    1.1526   16.39
240169................................................    0.9599   18.62
240170................................................    1.1056   17.65
240171................................................    1.0083   16.72
240172................................................    0.9741   14.91
240173................................................    0.9979   16.74
240179................................................    1.0343   16.65
240184................................................    0.9677   14.40
240187................................................    1.2492   17.51
240193................................................    1.0038   16.30
240200................................................    0.8955   14.73
240205................................................    0.9180  ......
240206................................................    0.8312  ......
240210*...............................................    1.2515   24.03
240211................................................    0.9639   20.55
250002................................................    0.8834   15.58
250003................................................    0.9935   15.66
250004................................................    1.5311   16.96
250006................................................    0.9628   15.70
250007................................................    1.2280   19.16
250008................................................    1.0292   13.32
250009................................................    1.2659   16.18
250010................................................    1.0112   13.34
250012................................................    0.9335   18.48
250015................................................    1.0386   11.07
250017................................................    1.0281   17.30
250018................................................    0.9366   13.47
250019................................................    1.4832   17.15
250020................................................    0.9513   13.88
250021................................................    0.8379    9.08
250023................................................    0.8948   13.54
250024................................................    0.8937   11.59
250025................................................    1.1497   17.72
250027................................................    0.9761   12.42
250029................................................    0.8705   14.85
250030................................................    0.9210   13.63
250031................................................    1.2477   18.77
250032................................................    1.2190   17.26
250033................................................    1.0137   15.76
250034................................................    1.5454   18.13
250035................................................    0.8365   17.41
250036................................................    0.9962   13.79
250037................................................    0.8845   10.32
250038................................................    0.9382   13.62
250039................................................    0.9970   16.51
250040................................................    1.3147   15.64
250042................................................    1.2629   16.47
250043................................................    0.8997   13.65
250045................................................    1.2675   19.48
250045................................................    1.6478   19.71
250047................................................    0.9058   31.60
250049................................................    0.8840   10.76
250050................................................    1.2669   13.92
250051................................................    0.9264    9.60
250057................................................    1.1777   13.76
250058................................................    1.1857   15.42
250059................................................    1.0828   14.23
250060................................................    0.7514    7.99
250061................................................    0.8571   13.97
250063................................................    0.8311   14.97
250065................................................    0.8934   12.68
250066................................................    0.9138   14.33
250067................................................    1.1596   15.29
250068................................................    0.8244   11.43
250069................................................    1.2682   15.77
250071................................................    0.8972   11.21
250072................................................    1.4321   16.93
250077................................................    0.9343   11.41
250078................................................    1.5470   15.50

[[Page 24779]]

 
250079................................................    0.8546   19.06
250081................................................    1.2791   28.31
250082................................................    1.4189   13.84
250083................................................    0.9426    9.20
250084................................................    1.0988   19.74
250085................................................    0.9829   13.85
250088................................................    0.9803   16.69
250089................................................    1.0904   13.05
250093................................................    1.1718   15.09
250094................................................    1.3373   17.85
250095................................................    0.9932   16.36
250096................................................    1.2105   17.07
250097................................................    1.2848   18.41
250098................................................    0.9421   14.30
250099................................................    1.2923   14.41
250101................................................    0.8831   16.31
250102................................................    1.5195   20.02
250104................................................    1.4439   17.54
250105................................................    0.9369   14.60
250107................................................    0.8803   13.63
250109................................................    0.8900   14.55
250109................................................    1.7757   18.47
250112................................................    0.9912   14.20
250117................................................    1.0628   14.52
250119................................................    1.0603   12.74
250120................................................    1.0638   14.41
250122................................................    1.1763   17.72
250123................................................    1.2209   17.41
250124................................................    0.9344   12.67
250125................................................    1.2793   14.49
250126................................................    0.9351   14.71
250127................................................    0.9230  ......
250128................................................    1.0367   13.00
250131................................................    1.0826   10.28
250134................................................    0.9667   17.98
250136................................................    0.9182   18.05
250138................................................    1.2054   17.60
250141................................................    1.2067   17.12
250145................................................    0.8696   11.40
250146................................................    0.9386   13.28
250148................................................    1.2354   11.98
250149................................................    0.9690   12.98
250150................................................    1.2560  ......
260001................................................    1.6327   17.55
260002................................................    1.4385   20.59
260003................................................    1.1303   14.33
260004................................................    0.9725   13.75
260004................................................    1.4534   18.46
260006................................................    1.5184   18.53
260008................................................    0.9887   16.25
260009................................................    1.2916   17.94
260011................................................    1.5348   18.32
260012................................................    1.0036   14.46
260013................................................    1.1872   15.54
260015................................................    1.1793   21.33
260017................................................    1.1724   15.80
260018................................................    0.8885   12.23
260019................................................    1.1438   23.67
260020................................................    1.8100   21.86
260020................................................    1.0367   11.27
260021................................................    1.4386   17.57
260022................................................    1.2556   19.35
260023................................................    1.4179   15.82
260024................................................    0.9716   13.47
260025................................................    1.3037   14.94
260027................................................    1.6145   21.01
260029................................................    1.1888   17.47
260030................................................    1.1362   11.24
260031................................................    1.5358   18.30
260032................................................    1.7220   20.92
260034................................................    1.0233   17.22
260035................................................    1.0045   12.59
260036................................................    1.0042   18.31
260039................................................    1.0672   14.20
260040................................................    1.6796   15.08
260042................................................    1.2519   17.44
260044................................................    1.0069   17.12
260047................................................    1.6390   17.28
260048................................................    1.2487   21.43
260050................................................    1.0545   18.74
260052................................................    1.3663   17.86
260053................................................    1.1247   12.01
260054................................................    1.3540   17.37
260055................................................    0.9667   17.76
260057................................................    1.0072   15.33
260059................................................    1.2431   15.79
260061................................................    1.1196   15.01
260062................................................    1.1845   20.26
260063................................................    1.0723   16.85
260064................................................    1.3319   16.50
260066................................................    1.0139   14.42
260067................................................    0.8926   12.16
260068................................................    1.6802   19.83
260070................................................    1.0377   21.69
260073................................................    1.0843   13.01
260074................................................    1.2962   15.42
260077................................................    1.7288   18.26
260078................................................    1.1814   15.48
260079................................................    1.0620   14.83
260080................................................    0.9887   12.56
260081................................................    1.6619   18.96
260082................................................    1.1478   15.79
260085................................................    1.5799   19.51
260086................................................    0.9285   14.87
260091................................................    1.6909   19.61
260094................................................    1.1873   15.87
260095................................................    1.3659   19.77
260096................................................    1.5613   21.72
260097................................................    1.1415   15.79
260100................................................    1.0128   15.73
260102................................................    0.9990   16.37
260103................................................    1.3189   17.35
260104................................................    1.7127   19.02
260105................................................    1.8623   20.80
260108................................................    1.8507   20.92
260109................................................    0.9915   13.44
260110................................................    1.6688   15.72
260113................................................    1.2254   14.79
260115................................................    1.2279   17.90
260116................................................    1.1034   14.57
260119................................................    1.2149   16.20
260120................................................    1.1954   17.13
260122................................................    1.0917   14.54
260123................................................    1.0482   14.00
260127................................................    1.0625   15.95
260129................................................  ........   14.64
260131................................................    1.2658   19.75
260134................................................    1.1709   16.58
260137................................................    1.7105   15.22
260138................................................    1.9075   21.41
260141................................................    1.9978   17.96
260142................................................    1.1255   16.03
260143................................................    0.9900   11.94
260147................................................    0.9530   13.66
260148................................................    0.9021   10.34
260158................................................    1.0544   12.40
260159................................................    1.0116   18.22
260160................................................    1.1476   16.19
260162................................................    1.5659   20.71
260163................................................    1.2449   14.81
260164................................................    0.9182   14.31
260166................................................    1.2191   19.53
260172................................................    0.9615   12.49
260173................................................    1.0061   11.98
260175................................................    1.1279   16.29
260176*...............................................    1.7243   19.59
260177................................................    1.3381   20.75
260178................................................    1.4663   21.20
260179................................................    1.6090   20.76
260180................................................    1.6591   18.54
260183................................................    1.6570   17.65
260186................................................    1.5847   18.06
260188................................................    1.2749   18.58
260189................................................    0.9425   10.75
260190................................................    1.1964   18.16
260191................................................    1.2874   19.34
260193................................................    1.2224   20.51
260195................................................    1.2469   15.95
260197................................................    1.0913   16.37
260198................................................    1.2980   17.64
260200................................................    1.2109   18.88
260205................................................    1.1102  ......
260206................................................    2.6705  ......
270002................................................    1.2837   17.19
270003................................................    1.2133   22.13
270004................................................    1.6933   29.28
270006................................................    0.8808   16.19
270007................................................    1.0011   13.17
270009................................................    1.0272   17.75
270011................................................    1.0451   19.82
270012................................................    1.6015   23.08
270013................................................  ........   20.40
270014................................................    1.8492   18.48
270016................................................    0.9184   19.77
270017................................................    1.2649   19.58
270019................................................    1.0264   12.78
270021................................................    1.1688   16.65
270023................................................    1.2657   20.40
270026................................................    0.9058   16.07
270027................................................    1.0591    9.78
270028................................................    1.1731   17.21
270029................................................    0.9220   17.89
270032................................................    1.1300   17.03

[[Page 24780]]

 
270033................................................    0.8642   16.46
270035................................................    1.0008   17.65
270036................................................    0.9192   14.08
270039................................................    1.0442   15.35
270040................................................    1.1242   19.19
270041................................................    1.0456   16.78
270044................................................    1.1398   13.46
270046................................................  ........   17.10
270048................................................    1.0107   15.84
270049................................................    1.7664   21.17
270050................................................    0.9917   18.04
270051................................................    1.3153   20.23
270052................................................    1.0056   14.80
270057................................................    1.2986   20.01
270058................................................    0.9229   14.07
270059................................................    0.7512   15.60
270060................................................    0.9524   14.02
270063................................................    0.9338   14.23
270073................................................    1.0809   15.53
270074................................................    0.8747  ......
270075................................................    0.8274  ......
270079................................................    0.9338   17.80
270080................................................    1.1410   11.35
270081................................................    0.9579   15.52
270082................................................    1.1020   16.13
270083................................................    1.0098   20.82
270084................................................    0.9151   16.66
280001................................................    1.0632   17.89
280003................................................    2.1214   22.00
280005................................................    1.3518   18.75
280009................................................    1.7680   18.70
280010................................................    0.8073   16.54
280011................................................    0.8552   13.96
280012................................................  ........   16.41
280013................................................    1.7249   22.18
280014................................................    0.9006   15.24
280015................................................    1.0730   14.64
280017................................................    1.0693   14.19
280020................................................    1.8118   19.40
280021................................................    1.1765   16.69
280022................................................    0.9681   15.71
280023................................................    1.3951   21.30
280024................................................    0.9612   13.91
280025................................................    0.9725   14.27
280025................................................    0.9215   13.56
280026................................................    1.0478   16.06
280028................................................    1.0763   15.89
280029................................................    1.2096   19.46
280030*...............................................    1.7665   33.26
280031................................................    0.9937   13.22
280032................................................    1.3465   19.18
280033................................................    1.0807   14.93
280034................................................  ........   15.28
280035................................................    0.9131   15.33
280037................................................    1.0308   16.17
280038................................................    1.0606   16.47
280039................................................    1.0637   15.19
280040................................................    1.7299   18.97
280041................................................    0.9617   13.39
280042................................................    1.0305   15.30
280043................................................    0.9752   15.79
280045................................................    1.0415   14.23
280046................................................    1.0475   13.72
280046................................................    0.9996   17.09
280047................................................    1.1206   18.37
280048................................................    1.1137   14.07
280049................................................    1.0856   15.63
280050................................................    0.8924   15.34
280052................................................    1.0652   13.65
280054................................................    1.2488   17.58
280055................................................    0.9146   12.99
280056................................................    0.9322   14.02
280057................................................    0.9635   15.76
280058................................................    1.2363   17.88
280060................................................    1.6236   28.61
280061................................................    1.4119   17.95
280062................................................    1.1814   13.67
280064................................................    1.0153   15.51
280065................................................    1.2669   18.53
280066................................................    1.0217   11.64
280068................................................    0.9304   10.13
280070................................................    0.9912   13.74
280073................................................    0.9848   14.79
280074................................................    0.9716   15.22
280075................................................    1.1052   13.79
280076................................................    1.0343   13.92
280077................................................    1.3025   19.01
280077................................................    1.3234   23.89
280079................................................    1.0819    9.91
280080................................................    1.0579   14.35
280081................................................    1.7240   20.92
280082................................................    1.0785   13.13
280083................................................    1.0611   17.55
280084................................................    0.9595   11.69
280085................................................    0.8186   21.58
280088................................................  ........   21.64
280089................................................    0.8837   17.16
280090................................................    0.8017   14.72
280091................................................    1.0928   15.15
280092................................................    0.9075   14.20
280092................................................    1.2667   17.95
280094................................................    0.9966   15.89
280097................................................    1.0876   14.30
280098................................................    0.8804   10.17
280101................................................    1.0046   17.42
280102................................................  ........   12.94
280104................................................    0.9207   13.38
280105................................................    1.2360   18.78
280106................................................    1.0160   15.54
280107................................................    1.1351   13.46
280108................................................    1.0618   17.22
280109................................................    0.9496   11.06
280110................................................    0.9845   12.30
280111................................................    1.2660   23.10
280115................................................    0.9779   16.43
280117................................................    1.0965   16.82
280118................................................    0.9029   16.92
280119................................................    0.9435  ......
280123................................................  ........   20.77
280125................................................    1.2266  ......
290001................................................    1.6951   22.42
290002................................................    0.9418   16.63
290003................................................    1.6685   23.40
290005................................................    1.3281   17.80
290006................................................    1.2282   19.88
290007................................................    1.6911   29.69
290008................................................    1.2553   20.25
290009................................................    1.6213   22.74
290010................................................    1.1253   14.48
290011................................................    1.0959   16.44
290012................................................    1.3501   21.17
290014................................................    1.0289   18.38
290015................................................    0.9745   17.83
290016................................................    1.1219   12.81
290019................................................    1.3294   20.93
290020................................................    0.9828   26.15
290021................................................    1.6752   21.13
290022................................................    1.5923   24.08
290027................................................    0.8876   16.43
290029................................................    0.9227  ......
290032................................................    1.4102   22.79
290036................................................    0.5760   18.61
290038................................................    0.9313   23.14
290039................................................    1.3278   25.80
290041................................................    1.2669  ......
300001................................................    1.4837   21.40
300003................................................    2.0054   23.25
300005................................................    1.3435   19.99
300006................................................    1.1762   18.93
300007................................................    1.0889   19.34
300008................................................    1.2468   16.46
300009................................................    1.0545   20.01
300010................................................    1.2618   19.38
300011................................................    1.3250   21.24
300011................................................  ........   19.27
300013................................................    1.1145   18.97
300014................................................    1.2417   19.80
300015................................................    1.1214   19.92
300016................................................    1.2108   18.50
300017................................................    1.3267   22.34
300018................................................    1.3658   20.89
300019................................................    1.2426   20.61
300020................................................    1.3820   21.65
300021................................................    1.0741   17.35
300022................................................    1.1274   17.19
300023................................................    1.3989   20.39
300028................................................    1.2859   18.05
300029................................................    1.3196   20.90
300033................................................    1.0986   19.85
300034................................................    2.1601   23.52
310001................................................    1.7852   26.81
310002................................................    1.8508   26.61
310003................................................    1.2974   26.83
310005................................................    1.2946   23.05
310006................................................    1.2111   21.50
310008................................................    1.3295   24.95
310009................................................    1.3229   23.19
310010................................................    1.2488   21.11
310011................................................    1.2569   23.22
310012................................................    1.6481   26.32
310013................................................    1.3697   22.11
310014................................................    1.6478   28.70
310015................................................    2.0223   27.58

[[Page 24781]]

 
310016................................................    1.2886   25.72
310017................................................    1.3522   26.07
310018................................................    1.0775   24.53
310019................................................    1.6742   22.82
310020................................................    1.3766   19.27
310021................................................    1.5395   14.69
310022................................................    1.3224   20.73
310024................................................    1.3248   22.78
310025................................................    1.1869   22.58
310026................................................    1.2370   23.87
310027................................................    1.3153   21.77
310028................................................    1.2506   23.52
310029................................................    1.9412   23.20
310031................................................    2.7731   25.18
310032................................................    1.3215   23.30
310034................................................    1.2861   21.69
310036................................................    1.1416   19.82
310037................................................    1.3994   27.44
310038*...............................................    2.0125   25.33
310038*...............................................    2.0125   25.33
310038*...............................................    1.5187   17.94
310038*...............................................    1.5187   17.94
310039................................................    1.2510   22.03
310040................................................    1.2033   24.30
310041................................................    1.3451   23.78
310042................................................    1.2924   24.27
310043................................................    1.1890   22.09
310044................................................    1.3276   20.43
310045................................................    1.4835   28.21
310047................................................    1.3317   24.52
310048................................................    1.2890   23.33
310049................................................    1.2304   24.76
310050................................................    1.2126   22.59
310051................................................    1.3939   25.27
310052................................................    1.3013   22.58
310054................................................    1.3465   24.38
310057................................................    1.3027   20.45
310058................................................    1.1447   26.10
310060................................................    1.1968   19.11
310061................................................    1.2042   20.80
310063*...............................................    1.3466   21.90
310064................................................    1.3576   22.05
310067................................................    1.3003   22.27
310069................................................    1.2634   24.17
310070................................................    1.4213   25.04
310072................................................    1.3710   22.22
310073................................................    1.6733   25.62
310074................................................    1.3502   24.46
310075................................................    1.4191   26.46
310076................................................    1.4966   28.90
310077................................................    1.6653   25.06
310078................................................    1.4152   23.48
310081................................................    1.3497   23.89
310083................................................    1.2748   23.68
310084................................................    1.3299   24.09
310086................................................    1.2171   21.44
310087................................................    1.3363   20.89
310088................................................    1.1986   22.34
310090................................................    1.3887   24.24
310091................................................    1.2672   21.64
310092................................................    1.3184   22.34
310093................................................    1.1947   21.23
310096................................................    1.9874   26.30
310105................................................    1.2351   24.49
310108................................................    1.4307   23.23
310110................................................    1.2698   20.05
310111................................................    1.2535   21.72
310112................................................    1.3035   22.52
310113................................................    1.2899   22.95
310115................................................    1.2997   20.07
310116................................................    1.2877   25.24
310118................................................    1.2498   23.69
310120................................................    1.2025   21.69
310121................................................  ........   18.74
320001................................................    1.5282   17.85
320002................................................    1.3475   18.74
320003................................................    1.0738   15.35
320004................................................    1.2912   17.12
320005................................................    1.3136   19.87
320006*...............................................    1.3522   19.34
320009................................................    1.5961   17.68
320011................................................    1.1434   21.09
320012................................................    1.0462   16.00
320013................................................    1.1399   22.59
320014................................................    1.0829   15.97
320016................................................    1.1832   18.78
320017................................................    1.1293   18.15
320019................................................    1.5028   19.26
320021................................................    1.8076   15.29
320022................................................    1.2332   17.66
320023................................................    1.0237   16.42
320030................................................    1.1556   13.86
320031................................................    0.9451   13.99
320032................................................    0.9020   16.45
320033................................................    1.1699   20.31
320035................................................    1.0266   24.07
320037................................................    1.1663   17.08
320038................................................    1.2324   16.29
320046................................................    1.4430   20.43
320048................................................    1.4178   19.17
320057................................................    0.9720  ......
320058................................................    0.8862  ......
320059................................................    1.0641  ......
320060................................................    0.9268  ......
320061................................................    1.1304  ......
320062................................................    0.8542  ......
320063................................................    1.2511   19.83
320065................................................    1.2158   16.10
320067................................................    0.8657   57.24
320068................................................    0.8982   18.60
320069................................................    0.9785   11.31
320070................................................    0.9556  ......
320074................................................    1.0897   18.65
320079................................................    1.2128   19.42
330001................................................    1.1867   25.21
330002................................................    1.4494   28.92
330003................................................    1.3431   17.65
330004................................................    1.2951   19.59
330005................................................    1.6834   24.28
330006................................................    1.3333   25.46
330007................................................    1.3686   18.65
330008................................................    1.1791   17.76
330009................................................    1.3308   30.42
330010................................................    1.2833   14.74
330011................................................    1.2963   17.63
330012................................................    1.7216   29.82
330013................................................    2.0344   19.11
330014................................................    1.3868   27.44
330016................................................    0.9933   17.41
330019................................................    1.3623   32.45
330020................................................    1.0286   14.55
330023................................................    1.3016   24.27
330024................................................    1.8309   33.55
330025................................................    1.1142   16.03
330027................................................    1.4665   32.50
330028................................................    1.4110   27.08
330029................................................    1.1574   16.56
330030................................................    1.4176   15.06
330033................................................    1.3126   16.75
330034................................................    0.5350   30.78
330036................................................    1.2759   24.32
330037................................................    1.2231   16.00
330038................................................    1.1805   16.01
330039................................................  ........   12.47
330041................................................    1.2877   30.42
330043................................................    1.3072   27.15
330044................................................    1.2664   18.70
330045................................................    1.3750   27.17
330046................................................    1.4572   31.91
330047................................................    1.1976   17.53
330048................................................    1.2590   17.62
330049................................................    1.2689   19.31
330053................................................    1.2232   15.67
330055................................................    1.5716   28.99
330056................................................    1.4640   30.21
330057................................................    1.6852   18.34
330058................................................    1.3123   16.98
330059................................................    1.6000   31.58
330061................................................    1.2766   25.07
330062................................................    1.0980   15.28
330064................................................    1.4278   32.87
330065................................................    1.2356   18.37
330066................................................    1.2664   19.12
330067................................................    1.3300   20.94
330072................................................    1.4065   30.35
330073................................................    1.1715   15.88
330074................................................    1.2824   18.18
330075................................................    1.0926   17.26
330078................................................    1.4535   17.49
330079................................................    1.2821   16.76
330080................................................    1.2129   24.70
330084................................................    1.0650   23.03
330085................................................    1.2897   18.78
330086................................................    1.2267   30.69
330088................................................    1.0497   25.62
330090................................................    1.5603   18.68
330091................................................    1.3782   18.53
330092................................................    0.9905   12.65
330094................................................    1.2369   17.72
330095................................................    1.3277   18.34
330096................................................    1.1197   16.60
330097................................................    1.2448   16.96
330100................................................    0.9996   28.11

[[Page 24782]]

 
330101................................................    1.7924   29.22
330102................................................    1.2990   17.25
330103................................................    1.2013   16.48
330104................................................    1.4136   28.77
330106................................................    1.7000   35.87
330106................................................    1.2141   17.58
330107................................................    1.2746   28.08
330108................................................    1.2381   17.08
330111................................................    1.0714   15.20
330114................................................    0.9051   18.24
330115................................................    1.1308   16.56
330116................................................    0.8461   24.23
330118................................................    1.6337   20.76
330119................................................    1.7045   34.75
330121................................................    1.0146   14.77
330122................................................    1.0120   21.20
330125................................................    1.8884   22.57
330126................................................    1.1356   22.70
330127................................................    1.3758   28.67
330128................................................    1.3080   26.63
330132................................................    1.1999   14.70
330133................................................    1.3624   32.28
330135................................................    1.1989   18.33
330136................................................    1.3313   17.26
330140................................................    1.8200   19.50
330140................................................    1.3693   29.22
330144................................................    0.9879   12.52
330148................................................    1.0686   15.04
330151................................................    1.0943   13.97
330152................................................    1.4603   29.48
330153................................................    1.7146   17.40
330154................................................    1.7635  ......
330157................................................    1.3770   20.82
330159................................................    1.2596   17.87
330160................................................    1.4253   30.17
330162................................................    1.2101   27.72
330163................................................    1.2553   20.46
330164................................................    1.3684   19.48
330166................................................    1.0688   14.18
330167................................................    1.7206   30.07
330169................................................    1.4402   25.15
330171................................................    1.3082   25.43
330177................................................    0.9538   14.54
330179................................................    0.8481   12.69
330180................................................    1.2145   14.94
330181................................................    1.3234   32.47
330182................................................    2.5161   31.33
330184................................................    1.3694   27.49
330185................................................    1.2686   26.89
330188................................................    1.2751   18.72
330189................................................    1.1706   17.66
330191................................................    1.3142   18.85
330193................................................    1.3060   29.82
330194................................................    1.8125   35.57
330194................................................    1.3303   24.74
330196................................................    1.2593   26.62
330197................................................    1.1217   17.00
330198................................................    1.3920   23.63
330199................................................    1.3788   27.66
330201................................................    1.6461   30.33
330202................................................    1.3273   31.24
330203*...............................................    1.3894   19.24
330204................................................    1.3574   26.81
330205................................................    1.2183   19.46
330208................................................    1.2533   25.82
330209................................................    1.2122   24.88
330211................................................    1.1003   19.10
330212................................................    1.1260   21.18
330213................................................    1.1307   18.51
330214................................................    1.8224   32.20
330218................................................    1.0787   21.71
330219................................................    1.6427   20.48
330221................................................    1.2963   30.00
330222................................................    1.2742   17.71
330223................................................    1.0460   17.28
330224................................................    1.2634   20.89
330225................................................    1.1993   25.80
330226................................................    1.2803   17.67
330229................................................    1.2988   16.25
330230................................................    1.3375   28.86
330230................................................    1.3883   30.32
330231................................................    1.0207   26.61
330232................................................    1.2609   19.50
330233................................................    1.4708   33.48
330234................................................    2.3386   32.95
330235................................................    1.1656   19.45
330236................................................    1.3899   29.54
330238................................................    1.2178   14.80
330239................................................    1.2090   17.28
330241................................................    2.0171   22.60
330242................................................    1.2839   24.74
330245................................................    1.4700   17.28
330245................................................    1.3066   17.65
330246................................................    1.3232   26.51
330247*...............................................    0.8513   27.71
330249................................................    1.1964   16.48
330250................................................    1.2370   19.20
330252................................................  ........   17.04
330254................................................    1.1706   16.73
330258................................................    1.2649   30.47
330259................................................    1.4768   23.87
330261................................................    1.3026   26.17
330263................................................    1.0017   19.64
330264................................................    1.1964   23.14
330265................................................    1.3296   15.62
330267................................................    1.3404   23.56
330268................................................    0.9562   14.62
330270................................................    2.0235   28.24
330273................................................    1.2927   25.89
330275................................................    1.3100   17.41
330275................................................    1.5329   17.72
330276................................................    1.1583   17.75
330277................................................    1.1061   17.16
330279................................................    1.2903   19.91
330285................................................    1.8644   22.47
330286................................................    1.3310   25.09
330290................................................    1.7051   31.84
330293................................................    1.1270   15.38
330304................................................    1.2324   29.51
330306................................................    1.3441   27.62
330307................................................    1.3062   20.74
330308................................................  ........   36.84
330327................................................    0.8784   16.97
330331................................................    1.3609   31.04
330332................................................    1.2164   27.16
330333................................................    1.2125   36.77
330333................................................    1.1649   18.57
330336................................................    1.3036   30.17
330338................................................    1.2490   22.14
330339................................................    0.9024   19.67
330340................................................    1.1793   26.92
330350................................................    1.7306   30.38
330353................................................    1.3031   33.55
330354................................................    1.5849  ......
330357................................................    1.3385   34.68
330359................................................  ........   29.29
330372................................................    1.2176   22.50
330381................................................    1.2997   29.24
330385................................................    1.1314   26.39
330386................................................    1.1741   24.67
330387................................................    0.7617  ......
330389................................................    1.7689   30.82
330390................................................    1.3621   29.79
330393................................................    1.7194   27.99
330394................................................    1.5580   18.54
330395................................................    1.3507   36.12
330396................................................    1.1230   28.11
330397................................................    1.3749   31.00
330399................................................    1.2641   35.55
330400................................................    0.8760  ......
340001................................................    1.4552   18.47
340002................................................    1.8350   18.79
340002................................................    1.6766   19.97
340003................................................    1.1378   21.97
340004................................................    1.5051   17.89
340005................................................    1.1264   14.09
340006................................................    1.0454   15.57
340007................................................    1.1632   17.17
340008................................................    1.1038   18.38
340009................................................  ........   20.50
340011................................................    1.1008   14.92
340012................................................    1.1768   16.66
340013................................................    1.2426   17.43
340014................................................    1.5356   19.86
340015................................................    1.2423   19.01
340016................................................    1.1688   16.40
340017................................................    1.2562   19.22
340018................................................    1.1436   15.16
340019................................................    0.9955   11.80
340020................................................    1.2435   16.75
340021................................................    1.2560   19.67
340022................................................    1.1245   16.72
340023................................................    1.3399   15.75
340024................................................    1.1416   16.64
340025................................................    1.2473   16.82
340027................................................    1.2113   17.30
340030................................................    2.0492   20.05
340031................................................    0.9575   12.39
340031................................................    1.2347   19.73
340032................................................    1.3541   20.47
340035................................................    1.0956   18.10
340036................................................    1.1309   16.97
340037................................................    1.0053   15.53

[[Page 24783]]

 
340038................................................    1.1024   17.01
340039................................................    1.2595   20.01
340040................................................    1.7834   20.07
340041................................................    1.2546   18.97
340042................................................    1.1890   16.63
340044................................................    1.1035   16.37
340045................................................    1.0223   12.42
340047*...............................................    1.8843   19.30
340048................................................    0.6134   13.11
340049................................................    0.7590   16.50
340051................................................    1.2900   18.60
340051................................................    1.8432   20.66
340052................................................    0.9876   21.37
340053................................................    1.6323   19.49
340054................................................    1.1763   14.47
340055................................................    1.2604   18.18
340060................................................    1.0860   17.83
340061................................................    1.7099   20.76
340063................................................    1.0057   17.19
340064................................................    1.1560   17.26
340065................................................    1.3378   18.32
340067................................................    1.0061   18.61
340068................................................    1.2336   16.70
340069................................................    1.8138   20.05
340070................................................    1.2544   18.38
340071................................................    1.1438   16.37
340072................................................    1.1338   15.60
340073................................................    1.3879   20.69
340075................................................    1.2367   18.21
340080................................................    0.9831   16.85
340084................................................    1.1281   21.78
340085................................................    1.1702   16.24
340087................................................    1.1121   16.70
340088................................................    1.2513   19.83
340089................................................    0.9805   13.86
340090................................................    1.1718   17.47
340093................................................    1.0391   15.16
340094................................................    1.3870   18.39
340096................................................    1.1754   17.98
340097................................................    1.1310   18.42
340098................................................    1.5829   20.17
340099................................................    1.1295   15.09
340101................................................    1.0709   15.36
340104................................................    0.8681   15.87
340105................................................    1.3491   18.91
340106................................................    1.1393   18.08
340107................................................    1.2314   16.95
340109................................................    1.3469   17.96
340111................................................    1.1160   14.49
340112................................................    0.9984   14.52
340113................................................    1.8531   21.03
340114................................................    1.6133   20.82
340115................................................    1.5465   18.67
340116................................................    1.8578   19.23
340119................................................    1.2151   16.85
340120................................................    1.1381   14.38
340121................................................    1.0491   15.97
340123................................................    1.1262   16.22
340124................................................    1.1113   14.05
340125................................................    1.4577   19.63
340126................................................    1.3187   17.72
340127................................................    1.3001   17.28
340130................................................    1.3606   19.40
340131................................................    1.5381   18.94
340132................................................    1.2828   16.94
340133*...............................................    1.0724   14.35
340137................................................    1.2697  ......
340138................................................    1.0673   19.28
340141................................................    1.7101   22.23
340142................................................    1.1894   16.09
340143................................................    1.4503   20.95
340144................................................    1.2523   15.98
340145................................................    1.3242   19.20
340146................................................    1.0434   13.01
340147................................................    1.2397   19.11
340148................................................    1.3626   19.61
340151................................................    1.2105   16.57
340155................................................    1.3964   20.42
340156................................................    0.7272  ......
340158................................................    1.0734   17.26
340159................................................    1.1779   16.80
340160................................................    1.1654   15.53
340162................................................  ........   16.64
340164................................................    1.3649   19.68
340166................................................    1.3051   19.22
340168................................................    0.4822   14.75
340171................................................    1.1342   20.05
340173................................................    1.2028   20.21
350001................................................    0.9646   15.10
350002................................................    1.8458   17.28
350003................................................    1.2077   17.43
350004................................................    1.9288   17.90
350005................................................    1.0897   16.03
350006................................................    1.3848   16.62
350007................................................    0.9036   13.28
350008................................................    0.9721   21.70
350009................................................    1.1842   18.28
350010................................................    1.1308   15.28
350011................................................    1.9255   18.49
350012................................................    1.0794   12.73
350013................................................    1.0590   16.68
350014................................................    1.0303   15.79
350015................................................    1.7237   15.87
350016................................................  ........   11.63
350017................................................    1.3344   17.78
350018................................................    1.0338   13.64
350019................................................    1.7223   19.40
350021................................................    0.9859   12.69
350023................................................    0.9505   13.34
350024................................................    1.0054   14.37
350025................................................    0.9807   16.24
350027................................................    1.0099   17.12
350029................................................    0.8409   12.80
350030................................................    1.0670   17.35
350033................................................    0.9292   14.90
350034................................................    0.9296   18.32
350035................................................    0.8734   10.16
350038................................................    1.0785   18.74
350039................................................    1.0406   17.31
350041................................................    0.9448   14.68
350042................................................    1.0516   16.75
350043................................................    1.6090   17.16
350044................................................    0.9036   10.53
350047................................................    1.1408   17.93
350049................................................    1.2037   14.53
350050................................................    0.9242   10.57
350051................................................    0.9872   17.53
350053................................................    1.0058   13.94
350055................................................    0.9910   12.37
350056................................................    0.9210   14.67
350058................................................    0.9553   14.35
350060................................................    0.8626    9.60
350061................................................    1.0444   14.59
350063................................................    0.8913  ......
350064................................................    0.8650  ......
350068................................................    2.5336  ......
350069................................................    1.1398  ......
360001................................................    1.3040   17.61
360002................................................    1.1823   17.40
360003................................................    1.7502   22.03
360006................................................    1.9071   22.09
360007................................................    1.0921   17.10
360008................................................    1.2559   18.28
360009................................................    1.5436   17.53
360010................................................    1.2815   18.09
360011................................................    1.2938   18.95
360012................................................    1.3003   19.22
360013................................................    1.1471   20.81
360014................................................    1.1215   19.88
360016................................................    1.6714   18.71
360017................................................    1.9258   22.50
360018*...............................................    1.6881   21.13
360019................................................    1.2251   20.17
360020................................................    1.4563   22.96
360024................................................    1.3152   18.54
360025................................................    1.3536   19.19
360026................................................    1.3138   17.04
360027................................................    1.4730   20.43
360028................................................    1.4907   17.27
360029................................................    1.1938   18.22
360030................................................    1.3469   15.35
360031................................................    1.1971   19.90
360032................................................    1.1591   17.93
360034................................................    1.3273   15.56
360035................................................    1.6456   18.97
360036................................................    1.3111   19.14
360037*...............................................    2.1426   22.52
360038................................................    1.6235   19.09
360039................................................    1.2937   17.52
360040................................................    1.2913   18.12
360041................................................    1.2871   18.42
360042................................................    1.1662   16.12
360044................................................    1.1478   16.79
360045................................................    1.4244   21.18
360046................................................    1.1481   19.32
360047................................................    1.1315   15.34
360048*...............................................    1.8813   21.29
360049................................................    1.2245   18.81
360050................................................    1.2304   12.89
360051................................................    1.6220   20.71
360052*...............................................    1.6960   19.75
360054................................................    1.2429   16.19
360055................................................    1.3166   23.27

[[Page 24784]]

 
360056................................................    1.3960   18.36
360057................................................    1.0590   13.81
360058................................................    1.1936   17.92
360059................................................    1.6088   20.39
360062................................................    1.4087   20.31
360063................................................    1.1347   22.79
360064................................................    1.6113   20.64
360065................................................    1.2531   19.45
360066................................................    1.6390   20.03
360067................................................    1.1463   14.57
360068................................................    1.7916   21.92
360069................................................    1.1347   17.88
360070................................................    1.7820   17.55
360071................................................    1.4177   23.80
360072................................................    1.2731   17.97
360074*...............................................    1.2996   18.32
360075................................................    1.3460   19.25
360076................................................    1.3579   19.59
360077................................................    1.6157   20.82
360078................................................    1.2427   20.79
360079*...............................................    1.8438   22.00
360080................................................    1.1427   16.66
360081................................................    1.3387   19.64
360082................................................    1.2779   22.86
360083................................................  ........   18.46
360084................................................    1.6077   20.09
360085................................................    1.8767   20.73
360086................................................    1.4308   17.04
360087................................................    1.4296   20.04
360088................................................    1.3224   22.31
360089................................................    1.1349   20.56
360090................................................    1.2682   20.40
360091................................................    1.3213   21.03
360092................................................    1.1373   15.91
360093................................................    1.1774   18.57
360094................................................    1.3412   18.31
360095................................................    1.2596   18.71
360096................................................    1.0736   17.16
360098................................................    1.4620   18.34
360099................................................    0.9911   16.43
360100................................................    1.2362   17.66
360101................................................    1.3303   22.31
360102................................................    1.2046   16.41
360103................................................  ........   22.66
360104................................................    1.1889  ......
360106................................................    1.1909   16.18
360107................................................    1.2449   14.54
360108................................................    1.0519   16.51
360109................................................    1.1015   19.52
360112................................................    1.9154   22.68
360113................................................    1.3257   22.27
360114................................................    1.0880   17.13
360115................................................    1.3591   18.19
360116................................................    1.1091   18.08
360118................................................    1.3515   18.60
360121................................................    1.2071   21.42
360123................................................    1.2382   19.13
360125................................................    1.1479   18.17
360126................................................    1.2125   20.46
360126................................................    1.8377  ......
360127................................................    1.1473   16.92
360128................................................    1.1568   15.58
360129................................................    0.9446   15.42
360130................................................    1.0122   15.34
360131................................................    1.3308   18.29
360132................................................    1.4132   18.27
360133................................................    1.6508   19.03
360134................................................    1.7520   20.24
360136................................................    1.0180   17.85
360137................................................    1.7424   20.26
360140................................................    0.9460   19.13
360141................................................    1.6432   22.85
360142................................................    1.0527   17.32
360143................................................    1.3343   20.44
360144................................................    1.2946   21.92
360145................................................    1.6897   19.39
360147................................................    1.2436   16.59
360148................................................    1.1482   18.89
360149................................................    1.2611   18.79
360150................................................    1.3025   20.63
360150................................................    1.3486   14.24
360151................................................    1.3908   17.49
360152................................................    1.5270   22.00
360153................................................    1.1281   14.89
360154................................................    1.0435   13.78
360155................................................    1.3677   20.90
360156................................................    1.2714   17.92
360159................................................    1.1769   20.71
360161*...............................................    1.3552   19.43
360162................................................    1.0718   18.32
360163................................................    1.8472   20.38
360164................................................  ........   16.16
360165................................................    1.1740   19.48
360166................................................  ........   16.98
360170................................................    1.4424   17.18
360172................................................    1.3450   18.47
360172................................................    1.0594   11.46
360174................................................    1.2393   19.09
360175................................................    1.1888   20.41
360176................................................    1.1416   15.55
360177................................................    1.3276   19.41
360178................................................    1.3155   17.40
360179................................................    1.4147   18.82
360180................................................    2.1660   22.09
360184................................................    0.5560   19.35
360185................................................    1.2279   18.67
360186................................................    1.0613   20.86
360187................................................    1.4008   18.02
360188................................................    0.9300   17.53
360188................................................    1.3145   19.84
360189................................................    1.0999   17.37
360192................................................    1.3351   21.00
360193................................................  ........   17.67
360194................................................    1.1660   17.69
360195................................................    1.1446   19.02
360197................................................    1.1572   19.42
360200................................................    0.9136   17.76
360203................................................    1.1642   15.61
360204................................................    1.2012   19.35
360210................................................    1.1861   20.28
360211................................................    1.2583   19.58
360212................................................    1.3502   20.23
360213................................................    1.2562   18.33
360218................................................    1.3312   18.41
360230................................................    1.5295   21.44
360231................................................    1.1521   13.56
360234................................................    1.3657   22.06
360236................................................    1.2693   19.57
360239................................................    1.2655   19.86
360241................................................    0.4070   22.08
360243................................................    0.6871   13.58
360244................................................  ........   10.55
360245................................................    0.7435   15.06
360247................................................    0.4015   18.11
360248................................................  ........   21.65
370001................................................    1.7396   21.23
370002................................................    1.2252   14.08
370004................................................    1.1874   16.77
370005................................................    0.9385   17.38
370006................................................    1.1866   12.54
370007................................................    1.1476   17.00
370008................................................    1.3755   17.30
370011................................................    1.0368   14.64
370012................................................    0.8370   10.80
370013................................................    1.8507   18.04
370014................................................    1.1884   19.63
370015................................................    1.1919   17.91
370016................................................    1.3306   16.64
370017................................................    1.1140   12.98
370019................................................    1.3158   16.88
370020................................................    1.2742   13.48
370021................................................    0.8613   11.26
370022................................................    1.3170   17.90
370023................................................    1.2564   16.82
370025................................................    1.3094   16.40
370026................................................    1.4938   16.90
370028................................................    1.8978   19.71
370029................................................    1.1615   13.89
370030................................................    1.1993   15.47
370032................................................    1.5960   16.70
370033................................................    1.0434   12.39
370034................................................    1.2300   14.51
370034................................................    1.1035   13.64
370035................................................    1.7244   18.96
370037................................................    1.7347   17.75
370038................................................    0.9601   12.81
370039................................................    1.1556   16.27
370040................................................    1.0121   14.34
370041................................................    0.9415   17.41
370042................................................    0.8490   14.61
370043................................................    0.9307   16.08
370045................................................    1.0379   12.44
370046................................................    0.9834   18.15
370047................................................    1.4255   15.67
370048................................................    1.2037   17.44
370051................................................    0.9449   12.18
370054................................................    1.3630   16.56
370056................................................    1.5715   18.88
370057................................................    1.0250   14.66
370059................................................    1.1266   16.46
370060................................................    1.0540   15.12
370063................................................    1.1044   17.06
370064................................................    0.9378    9.78

[[Page 24785]]

 
370065................................................    0.9995   16.56
370071................................................    1.0274   14.95
370072................................................    0.8645   26.05
370076................................................    1.2553   12.86
370077................................................  ........   17.62
370078................................................    1.6857   17.24
370079................................................    0.9312   13.60
370080................................................    0.9515   14.34
370082................................................    0.8548   13.57
370083................................................    0.9662   11.49
370084................................................    1.0191   21.75
370085................................................    0.8886   11.88
370086................................................    1.1148   13.56
370089................................................    1.2157   14.50
370091................................................    1.6647   17.58
370092................................................    0.9950   14.68
370093................................................    1.7953   18.57
370094................................................    1.4453   18.38
370095................................................    0.9872   14.13
370097................................................    1.3458   15.72
370099................................................    1.1231   16.17
370100................................................    0.9784   17.10
370103................................................    0.9071   15.90
370105................................................    1.9589   21.06
370106................................................    1.5282   18.62
370108................................................    0.9670   12.24
370112................................................    1.0284   15.25
370113................................................    1.2334   16.20
370114................................................    1.6444   15.98
370121................................................    1.0409   19.55
370122................................................    1.0451   12.15
370123................................................    1.4513   16.36
370125................................................    0.9024   13.55
370126................................................    0.9646   18.24
370131................................................    0.9766   16.24
370133................................................    1.0621   10.47
370138................................................    1.0490   16.02
370139................................................    1.0965   13.30
370140................................................    1.0464   15.23
370141................................................    1.3716    6.09
370146................................................    1.0935   12.56
370148................................................    1.4521  ......
370149................................................    1.3479   16.72
370153................................................    1.1151   15.32
370154................................................    1.0475   16.29
370158................................................    1.0197   15.09
370159................................................    1.2547   15.49
370163................................................    0.9790   14.56
370165................................................    1.2623   13.22
370166................................................    1.0457   17.82
370169................................................    1.0462   11.80
370170................................................    1.0246  ......
370171................................................    1.0343  ......
370172................................................    0.8992  ......
370173................................................    1.0625  ......
370174................................................    0.7213  ......
370176................................................    1.2190   16.03
370177................................................    0.9910   11.88
370178................................................    0.9838   11.64
370179................................................    0.9498   19.27
370180................................................    0.9870  ......
370183................................................    1.0383    7.62
370186................................................    0.9785   13.35
370190................................................    1.4695   13.70
370192................................................    1.4803   16.74
370196................................................    0.8822  ......
370197................................................  ........   21.57
370198................................................    1.4366  ......
370199................................................    1.0307  ......
370200................................................    1.1673  ......
380001................................................    1.3046   22.03
380002................................................    1.2175   19.48
380003................................................    1.1750   24.74
380004................................................    1.7385   23.16
380005................................................    1.1745   23.24
380006................................................    1.2246   20.54
380007................................................    1.6509   24.16
380008................................................    1.0680   21.19
380009................................................    1.7977   25.28
380010................................................    1.0413   19.75
380011................................................    1.1006   21.14
380013................................................    1.1883   20.10
380014................................................    1.6527   23.48
380017................................................    1.9295   23.68
380018................................................    1.8300   22.08
380019................................................    1.2442   20.77
380020................................................    1.4525   21.35
380021................................................    1.2077   20.64
380022................................................    1.1107   21.61
380023................................................    1.1378   19.24
380025................................................    1.2975   24.67
380026................................................    1.1414   19.27
380027................................................    1.2810   20.16
380029................................................    1.1411   18.57
380031................................................    0.9370   22.83
380033................................................    1.7968   22.62
380035................................................    1.3525   21.65
380036................................................    1.0858   19.33
380037................................................    1.2271   21.23
380038................................................    1.2457   25.58
380039................................................    1.2601   22.12
380040................................................    1.2922   21.64
380042................................................    1.0121   19.81
380047................................................    1.6765   21.95
380048................................................    1.0418   18.38
380050................................................    1.4266   18.25
380051................................................    1.6342   21.24
380052................................................    1.2506   17.77
380055................................................  ........   21.25
380056................................................    1.0970   17.16
380060................................................    1.4584   23.48
380061................................................    1.5207   22.63
380062................................................    1.2197   18.52
380063................................................  ........   19.36
380064................................................    1.3207   19.87
380065................................................    1.3101   22.17
380066................................................    1.3211   20.42
380068................................................  ........   22.76
380069................................................    1.0679   19.58
380070................................................    1.3454   24.71
380071................................................    1.2327   20.47
380072................................................    0.9961   16.32
380075................................................    1.4249   22.17
380078................................................    1.1368   19.10
380081................................................    1.0229   20.59
380082................................................    1.2627   22.58
380083................................................    1.1660   21.81
380084................................................    1.2367   23.64
380087................................................    1.2347   16.75
380088................................................    1.0722   19.52
380089................................................    1.2780   23.74
380090................................................    1.2983   27.09
380091................................................    1.2616   22.83
390001................................................    1.5197   16.39
390002................................................    1.3158   18.08
390003................................................    1.2403   17.24
390004................................................    1.3978   18.82
390005................................................    1.0949   15.36
390006*...............................................    1.8485   18.13
390009*...............................................    1.7387   20.16
390010................................................    1.2504   17.42
390011................................................    1.2787   18.07
390012................................................    1.2197   20.00
390013................................................    1.2401   19.33
390015................................................    1.1331   12.94
390016................................................    1.2482   17.95
390017................................................    1.1848   16.22
390018................................................    1.2431   18.98
390019................................................    1.0762   16.40
390022................................................    1.3535   22.86
390024................................................    1.1793   25.03
390026................................................    1.2757   22.18
390027................................................    1.7878   27.37
390028*...............................................    1.8892   18.48
390030................................................    1.2187   18.40
390031................................................    1.2151   18.69
390032................................................    1.2603   18.15
390035................................................    1.2652   18.51
390036................................................    1.5396   18.78
390039................................................    1.1414   16.54
390040................................................    0.9484   15.12
390041................................................    1.2691   19.58
390042................................................    1.5798   21.10
390043................................................    1.1762   16.36
390044................................................    1.6420   19.50
390045................................................    1.7171   18.75
390046................................................    1.6108   20.42
390047*...............................................    1.7435   23.61
390048................................................    1.1520   18.38
390049................................................    1.6125   21.02
390049................................................    1.7948   24.39
390050................................................    2.1150   21.43
390050................................................    1.2393   20.86
390051................................................    2.1342   26.05
390052................................................    1.1532   17.10
390054................................................    1.2344   17.50
390055................................................    1.8882   25.85
390056................................................    1.1202   17.17
390057................................................    1.3145   19.74
390058................................................    1.2840   19.25
390060................................................    1.2088   13.63
390061................................................    1.4935   16.95
390062................................................    1.2449   16.45

[[Page 24786]]

 
390063................................................    1.8347   19.51
390065................................................    1.2323   20.00
390066................................................    1.2608   18.70
390067................................................    1.8041   20.18
390068................................................    1.3029   17.55
390069................................................    1.2663   19.76
390070................................................    1.4168   20.07
390071................................................    1.1082   16.23
390072................................................    1.0501   15.56
390073................................................    1.6668   20.64
390074................................................    1.2477   16.60
390075................................................    1.3927   17.27
390076................................................    1.2793   21.43
390078................................................    1.1506   18.23
390079................................................    1.7570   17.76
390080................................................    1.2902   18.82
390081................................................    1.2995   23.99
390083................................................    1.2055  ......
390084................................................    1.2684   16.35
390086................................................    1.1376   17.25
390088................................................    1.3701   22.85
390090................................................    1.8017   20.68
390091................................................    1.1279   18.36
390093................................................    1.1549   16.61
390095................................................    1.2035   13.05
390096................................................    1.4931   19.25
390097................................................    1.2755   21.52
390100................................................    1.6536   19.89
390101................................................    1.2027   17.10
390102................................................    1.3963   19.51
390103................................................    1.0916   17.71
390104................................................    1.0666   16.17
390106................................................    1.1160   16.28
390107................................................    1.3258   19.18
390108................................................    1.4022   21.43
390109................................................    1.2016   14.66
390110................................................    1.5961   19.51
390111................................................    1.9406   26.03
390112................................................    1.2965   14.04
390113................................................    1.2515   17.53
390114................................................    1.2347   23.03
390115................................................    1.3973   24.42
390116................................................    1.2899   20.60
390117................................................    1.1722   16.90
390118................................................    1.2135   16.90
390119*...............................................    1.3898   18.48
390121................................................    1.3957   18.64
390122................................................    1.0603   17.46
390123................................................    1.2758   20.44
390125................................................    1.2067   15.94
390126................................................    1.2899   20.94
390127................................................    1.2286   21.88
390128................................................    1.2202   19.99
390130................................................    1.1343   17.33
390131................................................    1.3302   16.83
390132................................................    1.2935   21.10
390136................................................    1.1431   17.61
390137................................................    1.5156   16.54
390138................................................    1.3212   18.86
390139................................................    1.5084   22.94
390142*...............................................    1.6088   27.22
390145................................................    1.3880   20.34
390146................................................    1.2154   17.70
390147................................................    1.2654   21.11
390150................................................    1.1815   19.66
390151................................................    1.2305   20.51
390152................................................    1.1114   19.15
390153................................................    1.2214   23.14
390154................................................    1.2689   15.85
390156................................................    1.4094   20.88
390157................................................    1.3940   19.83
390158................................................  ........   21.69
390160................................................    1.2380   20.67
390161................................................    1.1893   12.37
390162................................................    1.5191   21.01
390163................................................    1.2262   15.64
390164*...............................................    2.1709   21.74
390166................................................    1.1125   19.96
390166................................................    1.1125   19.96
390167................................................  ........   22.91
390168................................................    1.2596   18.99
390169................................................    1.3383   18.99
390170................................................    1.8481   22.99
390173................................................    1.2222   17.82
390174*...............................................    1.6754   23.61
390176................................................    1.1817   17.36
390178................................................    1.3114   17.47
390179................................................    1.3111   21.16
390180................................................    1.4554   25.02
390181................................................    1.0732   17.09
390183................................................    1.1620   18.28
390184................................................    1.1309   20.75
390185................................................    1.2171   17.65
390189................................................    1.1411   18.67
390191................................................    1.1707   16.20
390192................................................    1.1740   16.32
390193................................................    1.1938   16.50
390194................................................    1.1395   20.15
390195................................................    1.8245   23.69
390196................................................    1.5792  ......
390197................................................    1.2825   18.99
390197................................................    1.3365   11.12
390198*...............................................    1.2667   15.51
390199................................................    1.2670   16.66
390200................................................    0.9701   13.59
390201................................................    1.2646   20.50
390203................................................    1.3562   22.06
390204................................................    1.2728   20.85
390206................................................    1.4000   16.78
390206................................................    1.4000   16.78
390209................................................    1.0811   16.96
390211................................................    1.2184   17.88
390213................................................    1.1284   17.17
390215................................................    1.2563   20.84
390217................................................    1.2232   19.29
390219................................................    1.3072   22.71
390220................................................    1.1652   18.52
390222................................................    1.3140   20.91
390223................................................    1.7334   22.13
390224................................................    0.8802   15.91
390225................................................    1.1951   18.17
390226................................................    1.6039   22.46
390228................................................    1.2976   19.81
390231................................................    1.5675   22.40
390231................................................    1.1916    9.56
390233................................................    1.3507   18.20
390235................................................    1.4144   23.54
390236................................................    1.2254   17.03
390237................................................    1.5705   19.89
390238................................................    1.2725    1.27
390238................................................    1.1545   10.04
390242................................................  ........   18.10
390244................................................    0.9245   14.41
390245................................................    1.3199   20.15
390246................................................    1.1920   17.75
390247................................................    1.0511   20.67
390249................................................    0.9293   10.73
390256................................................    1.8901   23.84
390258................................................    1.4575   21.36
390258................................................    1.3348   22.53
390260................................................    1.0990   21.19
390262................................................    1.9276   18.62
390263................................................    1.4224   23.62
390265................................................    1.2935   19.51
390266................................................    1.2118   16.24
390267................................................    1.2589   20.79
390268................................................    1.3375   21.02
390270................................................    1.3851   17.83
390272................................................    0.4768  ......
390277................................................    0.4015   27.10
390278................................................    0.6660   18.99
390283................................................    1.2887  ......
390284................................................    1.3639  ......
400001................................................    1.2182    9.86
400002................................................    1.6803    9.31
400003................................................    1.3589   10.13
400004................................................    1.1421    8.48
400005................................................    1.1211    7.85
400006................................................    1.1593    8.22
400007................................................    1.2021    7.86
400009................................................    1.0530    8.37
400010................................................    0.8902   11.66
400011................................................    1.0733    7.44
400012................................................    1.3428    7.81
400013................................................    1.2616    8.21
400014................................................    1.3935    9.54
400015................................................    1.3307   10.33
400016................................................    1.3663   12.07
400017................................................    1.1570    8.57
400018................................................    1.2817    9.45
400019................................................    1.6576   10.13
400021................................................    1.4432   11.68
400024................................................    0.9500    7.56
400026................................................    0.9640    7.12
400027................................................    1.1026    8.49
400028................................................    1.2500    8.40
400031................................................    1.2515    9.78
400032................................................    1.2212    9.42
400048................................................    1.0249    9.47
400061................................................    1.7094   16.08
400079................................................    1.2218  ......
400087................................................    1.4156    9.83
400094................................................    0.9947    5.15

[[Page 24787]]

 
400098................................................    1.3998    8.17
400102................................................    1.1591    7.73
400103................................................    1.3870   10.59
400104................................................    1.2767    9.68
400105................................................    1.2171   10.06
400106................................................    1.2574    8.51
400109................................................    1.4773   10.18
400110................................................    1.1292   10.52
400112................................................    1.0540    9.97
400113................................................    1.1575    9.48
400114................................................    1.0784    6.41
400115................................................    1.0386    9.13
400118................................................    1.2392    8.70
400120................................................    1.2554    9.74
400121................................................    0.9964    7.11
400122................................................    1.0235    8.48
400123................................................    1.2031    9.00
400124................................................    2.8358   11.16
400125................................................    1.0022  ......
410004................................................    1.2575   22.06
410005................................................    1.3735   21.26
410006................................................    1.3057   21.68
410007................................................    1.6365   20.98
410008................................................    1.2136   22.62
410009................................................    1.2941   24.08
410010................................................    1.1611   27.14
410011................................................    1.2705   24.37
410012................................................    1.9068   21.33
410013................................................    1.2981   25.01
420002................................................    1.5015   20.20
420004................................................    1.8164   19.41
420005................................................    1.1323   15.99
420006................................................    1.1199   18.24
420007................................................    1.5710   17.43
420009................................................    1.1697   17.25
420010................................................    1.1774   17.91
420011................................................    1.2438   14.99
420014................................................    1.0197   16.72
420015................................................    1.3348   17.18
420016................................................    0.9571   18.15
420018................................................    1.8110   19.73
420019................................................    1.2145   15.55
420020................................................    1.1846   20.16
420023................................................    1.4298   20.97
420026................................................    1.8901   21.90
420027................................................    1.3308   18.08
420030................................................    1.2081   17.82
420031................................................    0.8622   13.07
420033................................................    1.1653   21.09
420036................................................    1.2907   19.80
420037................................................    1.1948   21.96
420038................................................    1.3155   16.15
420039................................................    1.0701   16.96
420042................................................  ........   14.66
420043................................................    1.1867   18.36
420048................................................    1.2366   29.62
420049................................................    1.2046   19.23
420051................................................    1.6466   18.25
420053................................................    1.1427   16.48
420054................................................    1.2398   16.55
420055................................................    1.0585   16.18
420056................................................    1.1158   14.85
420057................................................    1.1156   14.50
420059................................................    0.9738   19.13
420061................................................    1.1761   17.78
420062................................................    1.1904   18.92
420064................................................    1.1038   16.15
420065................................................    1.3912   19.06
420066................................................    0.9834   15.52
420067................................................    1.2163   18.30
420068................................................    1.3854   17.21
420069................................................    1.0602   16.40
420070................................................    1.2331   17.45
420071................................................    1.3510   18.29
420072................................................    0.9129   12.34
420073................................................    1.2802   19.20
420074................................................    1.0257   13.80
420075................................................    0.9395   16.29
420078*...............................................    1.8578   20.68
420079................................................    1.5179   18.77
420080................................................    1.3722   24.83
420082................................................    1.5853   18.88
420083................................................    1.3596   20.41
420085................................................    1.4116   18.33
420086................................................    1.4340   19.31
420087................................................    1.5959   17.43
420088................................................    1.0878   17.09
420089................................................    1.2941   21.66
420091................................................    1.2732   18.57
420093................................................    1.0353   16.77
420094................................................  ........   32.68
430004................................................    0.9973   17.85
430005................................................    1.3588   15.92
430007................................................    1.0895   14.06
430008................................................    1.0971   16.54
430010................................................    1.1605   16.11
430011................................................    1.2930   16.42
430012................................................    1.3230   17.56
430013................................................    1.2073   17.24
430014................................................    1.3653   18.56
430015................................................    1.2134   16.41
430016................................................    1.8711   18.97
430018................................................    0.8815   15.15
430022................................................    0.8616   12.95
430023................................................    0.8729   11.64
430024................................................    0.9364   13.99
430026................................................  ........   10.85
430027................................................    1.7681   18.32
430028................................................    1.0724   16.78
430029................................................    0.9602   15.10
430031................................................    0.9138   12.46
430033................................................    0.9935   14.64
430034................................................    0.9461   12.85
430036................................................    0.9551   13.78
430037................................................    0.9633   15.95
430038................................................    1.0095   11.94
430040................................................    1.0511   13.37
430041................................................    0.9140   12.62
430043................................................    1.1323   13.43
430044................................................    0.9084   16.45
430047................................................    1.0274   17.06
430048................................................    1.2378   17.26
430049................................................    0.8812   14.44
430051................................................    0.9318   17.03
430054................................................    0.9648   13.50
430056................................................    0.8301   10.74
430057................................................    0.8972   15.15
430060................................................    1.0902    8.64
430062................................................  ........   10.89
430064................................................    1.0191   12.74
430065................................................  ........   12.77
430066................................................    0.9635   13.44
430073................................................    1.0646   14.98
430076................................................    0.9475   12.25
430076................................................    1.3562   15.61
430077................................................    1.6605   17.72
430079................................................    1.0029   12.98
430081................................................    0.8954  ......
430082................................................    0.8549  ......
430083................................................    0.9273  ......
430084................................................    0.8155  ......
430085................................................    0.7910  ......
430087................................................  ........   10.45
430089................................................    0.8333   17.01
430090................................................    1.3320  ......
430091................................................    1.4528  ......
430092................................................    2.2007  ......
430093................................................    0.9966  ......
440001................................................    1.1722   15.01
440002................................................    1.6649   24.36
440003................................................    1.2128   17.47
440006................................................    1.4058   20.39
440007................................................    1.0032    7.77
440008................................................    0.9784   14.04
440009................................................    1.1552   15.46
440010................................................    0.9307   13.59
440011................................................    1.3832   17.16
440012................................................    1.7143   18.79
440014................................................    1.0046   14.61
440015................................................    1.7923   21.09
440016................................................    1.0334   14.94
440017................................................    1.7422   20.93
440018................................................    1.2965   18.21
440019................................................    1.7372   28.22
440020................................................    1.1314   14.70
440022................................................  ........   19.02
440023................................................    1.1030   14.14
440024................................................    1.2947   18.10
440025................................................    1.1538   15.28
440026................................................    0.8073   22.92
440029................................................    1.2585   18.52
440030................................................    1.2098   15.57
440031................................................    1.0300   14.30
440031................................................    1.5024   19.61
440032................................................    1.0048   13.60
440033................................................    1.1602   14.04
440034................................................    1.5621   17.93
440035................................................    1.2301   18.16
440039................................................    1.8871   16.52
440040................................................    0.9687   17.50
440041................................................    1.0284   13.63
440046................................................    1.2336   16.83
440047................................................    0.9254   17.00

[[Page 24788]]

 
440048................................................    1.8710   18.14
440049................................................    1.6635   15.23
440050................................................    1.3867   16.76
440051................................................    0.9145   14.91
440052................................................    1.0633   16.27
440053................................................    1.3201   17.69
440054................................................    1.1349   12.31
440056................................................    1.1422   14.25
440057................................................    1.0340   12.72
440058................................................    1.2124   18.86
440059................................................    1.4182   17.53
440060................................................    1.1653   15.86
440061................................................    1.1496   16.48
440063................................................    1.6724   18.29
440064................................................    1.0863   17.38
440065................................................    1.2816   18.69
440067................................................    1.2422   28.28
440068................................................    1.2251   17.45
440070................................................    1.0077   15.04
440071................................................    1.3615   16.17
440073................................................    1.2785   18.56
440078................................................    1.0266   13.09
440081................................................    1.0950   17.97
440082................................................    2.0471   19.61
440083................................................    0.9670   59.16
440084................................................    1.2064   13.37
440091................................................    1.6371   19.72
440100................................................    1.0065   13.95
440102................................................    1.1313   13.96
440103................................................    1.1144   19.21
440104................................................    1.7388   22.39
440105................................................    1.7270   16.03
440109................................................    1.0889   14.25
440110................................................    1.1002   15.92
440111*...............................................    1.4426   21.12
440114................................................    1.0554   13.61
440115................................................    1.0675   12.97
440115................................................    1.4538   16.64
440120................................................    1.6404   18.30
440125................................................    1.5584   16.11
440130................................................    1.1384   16.67
440131................................................    1.1174   14.68
440132................................................    1.1314   15.91
440133................................................    1.5479   21.70
440135................................................    1.2196   35.34
440137................................................    1.0844   14.70
440141................................................    0.9706   12.48
440142................................................    1.0003   13.01
440143................................................    1.0461   17.33
440144................................................    1.2139   16.67
440145................................................    0.9559   13.66
440147................................................    1.7001   22.01
440148................................................    1.1231   17.64
440149................................................    1.0945   13.89
440150................................................    1.3319   13.04
440151................................................    1.1148   15.43
440152................................................    2.0165   17.84
440153................................................    1.1547   16.10
440157................................................    1.0819    9.02
440159................................................    1.1218   17.62
440161................................................    1.8684   20.39
440162................................................  ........   14.41
440166................................................    1.6849   18.14
440168................................................    1.0561   17.15
440173................................................    1.6008   18.47
440174................................................    1.0302   17.01
440175................................................    1.0716   17.29
440176................................................    1.3816   18.75
440180................................................    1.2237   17.01
440181................................................    0.9662   11.85
440182................................................    0.9596   18.91
440183................................................    1.5917   19.43
440184................................................    1.2536   18.06
440185................................................    1.1857   18.73
440186................................................    1.0479   18.28
440187................................................    1.1048   14.46
440189................................................    1.4799   16.19
440192................................................    1.0810   19.97
440193................................................    1.2265   18.40
440194................................................    1.2532   19.21
440197................................................    1.3616   23.08
440200................................................    1.0421   15.85
440203................................................    0.9727   16.61
440206................................................    0.9468   13.75
440209................................................  ........   14.75
440210................................................    0.8584   12.33
440211................................................    0.7073  ......
440212................................................    1.3679  ......
440213................................................    2.6309  ......
440214................................................    1.3295  ......
450002*...............................................    1.5334   19.92
450004................................................    1.1433   15.28
450005................................................    1.1877   15.66
450007................................................    1.2689   15.75
450008................................................    1.2584   15.75
450010................................................    1.4340   16.08
450011................................................    1.5214   17.66
450014................................................    1.1172   18.22
450015*...............................................    1.6355   16.44
450016................................................    1.6644   17.31
450018................................................    1.4434   19.81
450020................................................    0.9601   16.97
450021................................................    1.8595   22.03
450024................................................    1.4525   16.10
450024................................................    1.6146   15.16
450025................................................    1.7316   16.44
450028................................................    1.5003   18.28
450029................................................    1.6807   17.69
450031................................................    1.4829   20.90
450032................................................    1.3571   15.24
450033................................................    1.7144   20.86
450034................................................    1.5651   18.91
450035................................................    1.4731   16.91
450037................................................    1.5577   18.65
450039*...............................................    1.4262   18.83
450040................................................    1.5483   17.52
450042................................................    1.7715   17.01
450044................................................    1.6187   17.61
450046*...............................................    1.3251   16.99
450047................................................    1.1488   12.50
450050................................................    0.9407   13.00
450051................................................    1.5714   20.08
450052................................................    1.0002   13.53
450053................................................    1.1028   17.31
450054*...............................................    1.6343   21.98
450055................................................    1.1125   14.81
450056................................................    1.6257   19.22
450058................................................    1.6338   16.98
450059................................................    1.3021   14.21
450063................................................    0.9097   13.81
450064................................................    1.4200   15.43
450065................................................    1.0265   19.61
450068................................................    1.9331   22.90
450072................................................    1.1764   17.34
450073................................................    1.1207   16.62
450076................................................    1.7329  ......
450078................................................    0.8770   13.49
450079................................................    1.5311   19.49
450080................................................    1.1778   16.19
450081................................................    1.0574   16.17
450082................................................    0.9688   13.30
450083................................................    1.8071   20.18
450085................................................    1.0524   14.22
450087................................................    1.4467   21.44
450090................................................    1.1231   13.91
450092................................................    1.2254   15.68
450094................................................    1.3268   19.20
450096................................................    1.4156   16.63
450097................................................    1.3392   18.27
450098................................................    1.0981   15.48
450099................................................    1.1515   22.88
450101................................................    1.4797   15.29
450102................................................    1.7275   17.15
450104................................................    1.1833   15.96
450107................................................    1.5329   20.74
450108................................................    1.0388   13.53
450109................................................    0.9217   12.77
450110................................................  ........   21.44
450111................................................    1.2306   19.27
450112................................................    1.2588   12.04
450113................................................    1.3241   15.15
450118................................................    1.6610   15.83
450119................................................    1.4076   18.32
450121................................................    1.5363   17.37
450123................................................    1.1893   19.19
450124................................................    1.6632   20.61
450126................................................    1.3278   17.45
450128................................................    1.1963   15.62
450130................................................    1.5006   17.86
450131................................................    1.2640   17.62
450132................................................    1.6184   14.38
450133................................................    1.6016   19.64
450137................................................    1.5728   23.96
450140................................................    0.9222   18.07
450143................................................    1.0314   13.28
450144................................................    1.0945   16.30
450145................................................    0.8669   14.84
450146................................................    0.9518   13.75
450147................................................    1.3039   14.90
450148................................................    1.2199   16.91
450149................................................    1.4914   24.00
450150................................................    0.9050   12.56
450151................................................    1.1034   14.84

[[Page 24789]]

 
450152................................................    1.2307   17.33
450153................................................    1.5443   24.00
450154................................................    1.1796   11.36
450155................................................    1.0303   23.77
450157................................................    1.0679   14.62
450160................................................    0.9623    8.75
450162................................................    1.2163   22.12
450163................................................    1.0057   16.98
450164................................................    1.1844   19.21
450165................................................    1.0389   15.16
450166................................................    0.9373   10.28
450169................................................  ........   15.88
450170................................................    0.9628   13.96
450176................................................    1.2927   16.30
450177................................................    1.2044   15.38
450178................................................    1.0248   16.76
450181................................................    1.0084   14.02
450184................................................    1.4589   19.47
450185................................................    1.0264   13.06
450187................................................    1.1969   17.14
450188................................................    0.9950   13.78
450191................................................    1.0176   18.80
450192................................................    1.1764   21.53
450193................................................    2.0194   22.73
450194................................................    1.3017   19.15
450196................................................    1.4365   16.49
450200................................................    1.4455   17.38
450201................................................    1.0178   17.05
450203................................................    1.1592   18.66
450209................................................    1.5655   18.66
450210................................................    1.0520   14.23
450211................................................    1.3626   16.69
450213................................................    1.7288   17.44
450214................................................    1.3280   17.25
450217................................................    0.9354   11.69
450219................................................    1.0891   15.42
450221................................................    1.1920   16.99
450222................................................    1.4941   18.38
450224................................................    1.3678   22.83
450229................................................    1.5725   16.39
450231................................................    1.6282   13.25
450234................................................    1.0450   13.26
450235................................................    1.0681   13.42
450236................................................    1.1453   15.68
450237................................................    1.5262   17.40
450239................................................    1.0080   13.64
450241................................................    0.9562   13.66
450243................................................    0.9422   12.31
450246................................................    1.0110   18.31
450249................................................    1.0667   11.63
450250................................................    0.9906   14.91
450253................................................    1.1234   15.35
450258................................................    1.0358   13.23
450259................................................  ........   17.85
450264................................................    0.8807   13.89
450269................................................    0.9963   14.16
450270................................................    1.0793    9.86
450271................................................    1.2394   15.39
450272................................................    1.2614   17.91
450276................................................    1.0966   12.71
450278................................................    0.8254   13.79
450280................................................    1.5815   19.01
450283................................................    1.0413   13.89
450286................................................  ........   12.12
450288................................................    1.1566   15.67
450289................................................    1.4681   18.08
450293................................................    0.9461   14.43
450296................................................    1.3456   20.66
450299................................................    1.5412   17.97
450303................................................    0.9624   11.59
450306................................................    1.0914   13.32
450307................................................    0.7995   16.23
450309................................................    1.0981   11.91
450315................................................    0.9788   20.80
450320................................................    1.2431   19.63
450321................................................    0.9220   13.09
450322................................................    0.5973   12.33
450324................................................    1.5343   17.87
450327................................................    0.9680   15.98
450330................................................    1.1267   18.42
450334................................................    0.9752   12.27
450337................................................    0.9932   17.42
450340................................................    1.4589   15.85
450341................................................    1.0144   19.27
450346................................................    1.5017   14.22
450347................................................    1.2197   17.54
450348................................................    1.1296   12.94
450352................................................    1.1887   17.50
450353................................................    1.1374   15.00
450355................................................    1.0444   14.32
450358................................................    2.0739   18.73
450362................................................    1.0903   14.71
450369................................................    1.0535   15.17
450370................................................    1.2082   15.44
450371................................................    1.2448   11.90
450372................................................    1.2359   18.76
450373................................................    1.1042   17.60
450374................................................    0.8698   12.69
450378................................................    1.1823   23.06
450379................................................    1.5578   20.28
450381................................................    0.9504   13.57
450388................................................    1.7801   17.56
450389................................................    1.2887   18.15
450393................................................    1.2516   15.73
450395................................................    1.0414   13.48
450400................................................    1.3751   11.53
450411................................................    0.9314   13.56
450417................................................    1.0236   13.85
450418................................................    1.3841   20.58
450419................................................    1.2162   14.50
450422................................................    1.0412   24.33
450423................................................    1.5371   19.44
450424................................................    1.2463   17.09
450429................................................    1.1179   10.12
450431................................................    1.5626   34.88
450438................................................    1.1330   14.95
450446................................................    0.7612   21.97
450447................................................    1.3910   16.35
450451................................................    1.1844   18.35
450457................................................    1.8463   19.35
450460................................................    1.0034   16.62
450462................................................    1.7354   19.83
450464................................................    0.9328   10.87
450465................................................    1.3057   15.22
450467................................................    1.0766   15.02
450469................................................    1.3918   22.10
450473................................................    1.0190   14.19
450475................................................    1.0903   16.25
450484................................................    1.4886   19.59
450488................................................    1.3273   18.73
450489................................................    0.9699   12.93
450497................................................    1.1188   11.89
450498................................................    0.9736    0.87
450508................................................    1.3853   19.37
450514................................................    1.0764   22.28
450517................................................    0.9583   12.86
450518................................................    1.5216   18.98
450523................................................    1.4806   20.26
450530................................................    1.1943   22.91
450534................................................    0.9671   22.77
450535................................................    1.2284   21.26
450537................................................    1.3420   20.83
450538................................................  ........   19.69
450539................................................    1.2651   14.25
450544*...............................................    1.1442   19.38
450545................................................    1.3928   16.97
450547................................................    1.0633   13.81
450551................................................    1.1045   24.23
450558................................................    1.7912   20.15
450559................................................  ........   11.50
450561................................................  ........   16.82
450563................................................    1.2647   30.37
450565................................................    1.2567   16.45
450570................................................    1.1346   17.71
450571................................................    1.4908   16.80
450573................................................    0.9885   15.61
450574................................................    0.9302   14.24
450575................................................    1.1445   19.06
450578................................................    0.9365   16.87
450580................................................    1.1534   15.36
450583................................................    1.0350   15.50
450583................................................    1.1976   21.38
450584................................................    1.1771   12.42
450586................................................    1.0584   12.79
450587................................................    1.1745   17.11
450591................................................    1.1460   17.92
450596................................................    1.2182   14.82
450597................................................    0.9687   16.18
450603................................................    0.7880   12.77
450604................................................    1.3023   14.47
450605................................................    1.1873   20.15
450609................................................    0.8938   10.73
450610................................................    1.4674   16.49
450614................................................    0.9889   13.25
450615................................................    1.0755   14.75
450617................................................    1.3306   19.54
450620................................................    1.1230   12.27
450623................................................    1.1390   21.83
450626................................................    1.0109   18.56
450628................................................    1.0152   16.83
450630................................................    1.5199   19.19
450631................................................    1.6593   17.56
450632................................................    0.9391   11.63

[[Page 24790]]

 
450633................................................    1.5493   19.26
450634................................................    1.5955   20.29
450638................................................    1.5280   21.11
450639................................................    1.4800   20.14
450639................................................    1.1078   14.71
450641................................................    1.0511   13.50
450643................................................    1.2200   17.43
450643................................................    1.8171   18.65
450644................................................    1.4350   20.79
450644................................................    1.2078   17.67
450646................................................    1.4571   19.99
450647................................................    1.8915   22.10
450648................................................    1.0015   12.59
450649................................................    1.0322   15.37
450651................................................    1.6801   20.31
450652................................................    0.9063   15.24
450653................................................    1.0888   19.28
450654................................................    0.9486   13.41
450656................................................    1.3894   18.56
450658................................................    0.9605   15.15
450659................................................    1.4874   20.56
450661................................................    1.1066   20.22
450662................................................    1.4702   18.42
450665................................................    0.8639   13.60
450666................................................    1.3180   19.35
450668................................................    1.6257   18.50
450669................................................    1.3474   22.28
450670................................................    1.3446   18.20
450672................................................    1.5857   21.04
450673................................................    1.0157   13.84
450674................................................    1.1515   20.62
450675................................................    1.3677   23.26
450677................................................    1.3317   18.71
450678................................................    1.4729   20.75
450681................................................    1.3177  ......
450683................................................    1.2745   19.95
450684................................................    1.2398   22.85
450686................................................    1.5933   14.85
450688................................................    1.3163   20.90
450690................................................    1.3862   16.37
450694................................................    1.1409   18.03
450696................................................    1.3358   17.57
450697................................................    1.3692   15.93
450698................................................    0.9124   14.40
450700................................................    0.9465   15.12
450702................................................    1.5056   21.01
450703................................................    1.1321   18.80
450704................................................    1.2418   21.62
450705................................................    0.8800   22.32
450705................................................    1.7726   20.82
450709................................................    1.1858   17.96
450711................................................    1.6329   17.93
450712................................................    0.5447   16.89
450713................................................    1.4868   23.11
450715................................................    1.4311   19.11
450716................................................    1.2675   19.99
450716................................................    1.3205   16.71
450717................................................    1.2910   19.45
450718................................................    1.1993   19.07
450723................................................    1.4195   20.55
450724................................................    1.2576   20.07
450725................................................  ........   19.56
450727................................................    1.0735   17.75
450728................................................    0.8255   12.93
450730................................................    1.3987   20.88
450733................................................    1.4711   20.37
450735................................................    0.8297    8.00
450742................................................    1.2724   20.74
450743................................................    1.4594   14.65
450746................................................    0.9226   18.45
450747................................................    1.3312   17.38
450749................................................    1.0333   12.95
450750................................................    1.0162   14.72
450751................................................    1.2148   22.25
450754................................................    0.9405   14.89
450757................................................    0.8760   13.96
450761................................................    0.9449   11.14
450763................................................    1.0029   17.56
450766................................................    2.0829   18.19
450769................................................    0.8529   13.62
450770................................................    0.9940   15.51
450771................................................    1.9141   17.74
450774................................................    1.6697   16.52
450775................................................    1.3635   19.97
450776................................................    1.0096   10.19
450777................................................    0.9775   19.59
450779................................................    1.2926   22.97
450780................................................    1.7465   15.28
450785................................................    0.9897   18.55
450788................................................    1.5030   20.78
450794................................................  ........   18.40
450795................................................    0.9920   14.17
450796................................................    3.3883  ......
450797................................................    0.7701   18.59
450798................................................    0.7662    9.22
450801................................................    1.4574   16.35
450802................................................    1.4444   18.90
450803................................................    1.0998   16.20
450804................................................    1.7558   20.19
450807................................................    0.8919   13.23
450808................................................    1.9103   45.47
450809................................................    1.5476   12.09
450810................................................    0.9739  ......
450811................................................    2.4111   18.38
450812................................................  ........   20.74
450813................................................    0.9720  ......
450815................................................    2.5623  ......
450817................................................    0.6826  ......
450818................................................    1.1788  ......
450819................................................    1.2321  ......
450820................................................    1.0337  ......
450822................................................    1.2194  ......
460001................................................    1.7791   20.63
460003................................................    1.6039   20.60
460005................................................    1.6610   17.58
460006................................................    1.3361   19.65
460007................................................    1.3066   20.57
460008................................................    1.3692   23.97
460009*...............................................    1.8478   21.14
460010................................................    2.0938   21.25
460013................................................    1.4314   18.21
460014................................................    1.2150   16.70
460015................................................    1.2389   19.99
460016................................................    0.9921   18.08
460017................................................    1.4000    6.88
460018................................................    0.9273   16.86
460019................................................    1.0515   16.83
460020................................................    0.9556   17.03
460021................................................    1.3838   20.26
460022................................................    0.9569   18.21
460023................................................    1.1748   21.33
460024................................................  ........   13.03
460025................................................    0.8253   12.51
460026................................................    1.0648   17.34
460027................................................    0.9545   20.85
460029................................................    1.0958   17.45
460030................................................    1.1965   17.22
460032................................................    0.9812   19.55
460033................................................    0.9710   15.72
460035................................................    0.9482   10.14
460036................................................    1.0012   22.38
460037................................................    0.9093   18.77
460039................................................    1.0603   24.48
460041................................................    1.3034   21.69
460042................................................    1.3720   17.85
460043................................................    0.9896   23.90
460044................................................    1.1363   20.69
460046................................................  ........   17.11
460047................................................    1.6725   20.94
460049................................................    1.9835   18.82
460051................................................    1.1533   20.98
460052................................................    1.4619  ......
470001................................................    1.3024   19.61
470003................................................    1.8178   22.10
470004................................................    1.0690   18.10
470005................................................    1.2301   21.51
470006................................................    1.2402   18.39
470008................................................    1.2583   19.41
470010................................................    1.0674   19.47
470011................................................    1.1523   21.20
470012................................................    1.2771   18.52
470015................................................    1.2008   19.26
470018................................................    1.2257   20.77
470020................................................    0.9900   18.99
470023................................................    1.3178   20.34
470024................................................    1.1530   20.41
490001................................................    1.1947   24.76
490002................................................    1.0751   12.74
490003................................................    0.6419   18.00
490004................................................    1.2734   18.67
490005................................................    1.5964   16.91
490006................................................    1.2135   15.23
490007................................................    2.0980   18.43
490009................................................    1.9433   22.95
490010................................................    1.0335   18.58
490011................................................    1.4669   18.20
490012................................................    1.1951   13.78
490013................................................    1.2469   16.93
490014................................................    1.5363   24.56
490015................................................    1.5153   19.36
490017................................................    1.3909   15.07
490018................................................    1.3011   17.67
490019................................................    1.1928   16.93

[[Page 24791]]

 
490020................................................    1.2250   17.67
490021................................................    1.3802   19.45
490022................................................    1.5525   21.01
490023................................................    1.2187   18.87
490024................................................    1.6719   16.89
490027................................................    1.1135   14.46
490030................................................    1.1907   10.50
490031................................................    1.0746   15.82
490032*...............................................    1.7258   25.58
490033................................................    1.1993   18.33
490037................................................    1.2001   15.97
490038................................................    1.2145   15.71
490040................................................    1.4731   22.35
490041................................................    1.2784   16.55
490042................................................    1.2285   15.27
490043................................................    1.3526   20.68
490044................................................    1.3206   17.63
490045................................................    1.2191   19.63
490046................................................    1.5460   18.61
490047................................................    1.1059   17.16
490048................................................    1.5709   17.89
490050................................................    1.4272   22.71
490052................................................    1.6374   16.94
490053................................................    1.3173   15.69
490054................................................    1.0322   15.55
490057................................................    1.5692   19.07
490059................................................    1.5895   20.22
490060................................................    1.0646   19.20
490063................................................    1.7720   27.25
490066................................................    1.3206   17.88
490067................................................    1.2570   17.19
490069................................................    1.4162   13.29
490071................................................    1.4080   19.47
490074................................................  ........   13.34
490075................................................    1.3803   19.19
490077................................................    1.2281   19.79
490079................................................    1.3125   16.44
490079................................................    1.3236   23.38
490083................................................  ........   16.64
490084................................................    1.1288   16.38
490085................................................    1.1577   16.40
490088................................................    1.1207   20.76
490089................................................    1.0686   15.86
490090................................................    1.1204   16.35
490091................................................    1.2337   19.83
490092................................................    1.2211   12.97
490093................................................    1.4392   16.48
490094................................................    1.0907   16.79
490097................................................    1.2114   15.86
490098................................................    1.2065   14.70
490099................................................    0.9562   16.88
490100................................................  ........   17.22
490101................................................    1.2299   24.85
490104................................................    0.6981   28.49
490105................................................    0.5822   18.25
490106................................................    0.8713   16.91
490107................................................    1.3325   22.41
490107................................................    1.2448   21.42
490108................................................    0.8976   19.75
490109................................................    0.8779   21.16
490110................................................    1.3090   15.84
490111................................................    1.2008   17.34
490112................................................    1.6550   20.52
490112................................................    0.9491   21.43
490113................................................    1.3260   23.08
490114................................................    1.1579   16.91
490115................................................    1.1607   17.10
490116................................................    1.1694   16.44
490117................................................    1.1533   13.84
490119................................................    1.3405   17.87
490122................................................    1.3606   23.62
490123................................................    1.1354   16.85
490124................................................    1.0889   19.36
490126................................................    1.3233   17.07
490127................................................    1.0414   14.48
490129................................................    1.0562   27.47
490130................................................    1.3109   16.28
490132................................................    1.0184   17.02
500001................................................    1.4839   21.30
500002................................................    1.4064   21.04
500003................................................    1.3996   24.31
500005................................................    1.7494   23.48
500007................................................    1.3375   22.43
500007................................................    1.7377   27.24
500008................................................    1.9429   24.19
500011................................................    1.3347   25.18
500012................................................    1.5545   22.28
500014................................................    1.5643   23.93
500015................................................    1.3297   23.24
500016................................................    1.4969   23.90
500019................................................    1.3825   22.37
500019................................................    1.0542   16.63
500021................................................    1.4811   24.46
500023................................................    1.2084   27.19
500024................................................    1.6908   28.85
500025................................................    1.9076   23.96
500026................................................    1.4496   23.35
500027*...............................................    1.6837   25.11
500028................................................    1.0717   18.86
500029................................................    0.9116   17.15
500030................................................    1.4523   24.13
500031................................................    1.2466   23.37
500033................................................    1.3324   21.39
500036................................................    1.3903   21.89
500037................................................    1.1389   19.69
500039................................................    1.3777   23.32
500042................................................    1.4121   22.13
500043................................................    1.0020   20.25
500044................................................    1.9366   23.11
500045................................................    1.0116   22.10
500048................................................    0.9588   19.01
500049................................................    1.4726   22.95
500050................................................    1.3485   20.97
500051................................................    1.6734   24.48
500052................................................    1.1378  ......
500053................................................    1.3294   22.05
500054................................................    1.8773   22.90
500055................................................    1.1299   22.88
500057................................................    1.3026   18.04
500058................................................    1.4858   23.40
500059................................................    1.0767   22.54
500060................................................    1.3734   23.58
500061................................................    1.0038   20.40
500062................................................    1.0655   19.46
500064................................................    1.6399   24.53
500068................................................    1.0553   18.70
500069................................................    1.1143   20.63
500071................................................    1.2830   19.38
500072................................................    1.2022   24.46
500074................................................    1.1040   17.83
500077................................................    1.3318   22.93
500079................................................    1.3197   22.98
500080................................................    0.8124   13.80
500084................................................    1.2783   17.76
500085................................................    0.9278   28.61
500086................................................    1.2605   22.31
500088................................................    1.2964   23.71
500089................................................    1.0388   17.94
500090................................................    0.8380   16.33
500092................................................    1.0142   17.40
500094................................................    0.8826   18.11
500096................................................    0.9385   20.96
500097................................................    1.0798   19.71
500098................................................    1.0464   16.38
500101................................................    1.0138   19.45
500102................................................    0.9022   20.33
500104................................................    1.2658   22.58
500106................................................    0.9351   18.71
500107................................................    1.2050   17.30
500107................................................    1.2050   17.30
500107................................................    1.4730   20.61
500110................................................    1.2039   21.41
500118................................................    1.1500   22.92
500118................................................    1.2716   18.35
500119................................................    1.3565   21.57
500122................................................    1.2754   21.91
500123................................................    0.9512   19.58
500124................................................    1.3682   24.15
500129................................................    1.6395   23.60
500132................................................    0.9695   19.42
500134................................................    0.6470   20.96
500138................................................    3.6799  ......
500139................................................    1.4685   20.88
500140................................................  ........    1.00
500141................................................    1.3697   22.94
500143................................................    0.5986   17.60
500146................................................  ........   17.85
510001................................................    1.9505   17.87
510002................................................    1.2866   17.34
510005................................................    1.0195   14.43
510006................................................    1.2718   17.53
510007*...............................................    1.5744   20.25
510008................................................    1.2176   17.29
510012................................................    1.0090   20.21
510013................................................    1.1010   16.62
510015................................................    0.9623   14.56
510016................................................  ........   14.52
510018................................................    1.0667   16.48
510020................................................    1.0824   12.65
510022................................................    1.8964   19.84
510023................................................    1.2383   15.94
510024................................................    1.5822   18.80
510026................................................    1.0565   13.46

[[Page 24792]]

 
510027................................................    0.9592   17.58
510028................................................    1.0482   20.73
510029................................................    1.2825   17.05
510029................................................    1.1570   15.37
510030................................................    1.0525   18.31
510030................................................    1.1257   17.66
510031................................................    1.4148   18.49
510033................................................    1.2896   18.81
510035................................................    1.2262   18.65
510036................................................    0.9851   13.20
510038................................................    1.0644   14.34
510039................................................    1.3991   16.04
510043................................................    0.9349   14.29
510046................................................    1.2728   17.73
510047................................................    1.2608   19.12
510048................................................    1.1326   20.37
510050................................................    1.7469   16.57
510053................................................    1.0811   15.59
510055................................................    1.2272   22.84
510058................................................    1.2791   17.98
510059................................................    1.9378   16.77
510060................................................    1.0503   15.66
510061................................................    1.0234   14.22
510062................................................    1.2784   17.63
510065................................................  ........   13.72
510066................................................  ........   12.72
510067................................................    1.2058   18.11
510068................................................    1.2072   16.29
510070................................................    1.2966   16.36
510071................................................    1.3310   16.24
510072................................................    1.0568   17.66
510077................................................    1.1382   16.41
510080................................................    1.1488   14.80
510081................................................    1.0777   13.00
510082................................................    1.1599   13.38
510084................................................    1.0387   12.48
510086................................................    1.1038   13.79
510088................................................    1.0373  ......
520003................................................    1.0889   16.43
520004................................................    1.1781   18.17
520006................................................    1.0164   20.44
520007................................................    1.0498   13.11
520008................................................    1.6388   23.11
520009................................................    1.6963   18.51
520010................................................    1.1567   20.34
520011................................................    1.1930   20.38
520013................................................    1.3708   21.64
520014................................................    1.1081   16.40
520015................................................    1.1985   18.32
520016................................................    0.9785   13.29
520017................................................    1.1935   19.32
520018................................................    1.1169   18.64
520019................................................    1.3094   18.31
520021................................................    1.4602   19.46
520024................................................    1.0420   14.61
520025................................................    1.0655   18.11
520026................................................    1.0229   19.81
520027................................................    1.2629   18.86
520028................................................    1.3300   19.14
520029................................................    0.8925   16.75
520030................................................    1.7397   20.01
520031................................................    1.0727   18.71
520032................................................    1.2635   17.84
520033................................................    1.2390   18.77
520034................................................    1.1068   16.69
520035................................................    1.3242   17.10
520037................................................    1.7020   20.05
520038................................................    1.3352   17.71
520039................................................    0.9971   19.60
520040................................................    1.5273   20.48
520044................................................    1.4160   17.79
520045................................................    1.6446   19.67
520047................................................    0.9370   17.87
520048................................................    1.4946   18.61
520049................................................    2.0474   19.57
520051*...............................................    1.8401   19.06
520053................................................    1.1887   16.49
520054................................................    1.0540   15.99
520057................................................    1.1966   18.32
520058................................................    1.1064   18.13
520059................................................    1.4353   19.85
520060................................................    1.4753   17.05
520062................................................    1.2495   17.80
520063................................................    1.1851   20.77
520064................................................    1.5705   21.46
520066................................................    1.4668   22.24
520068................................................    0.9622   18.08
520069................................................    1.2302   17.00
520070................................................    1.5249   17.82
520071................................................    1.2534   18.75
520074................................................    1.0579   19.57
520075................................................    1.4850   19.09
520076................................................    1.1802   16.51
520077................................................    0.9304   15.54
520078................................................    1.6347   20.13
520082................................................    1.1943   16.74
520083................................................    1.7211   25.85
520084................................................    1.0805   18.95
520087................................................    1.6998   19.39
520088................................................    1.2750   20.15
520090................................................    1.2589   18.00
520091................................................    1.2781   20.07
520092................................................    1.0851   17.56
520094................................................    0.7814   19.78
520095................................................    1.2912   18.51
520096................................................    1.3837   19.30
520097................................................    1.3186   19.57
520098*...............................................    1.7679   20.03
520100................................................    1.2558   18.38
520101................................................    1.0673   17.85
520102................................................    1.1747   19.83
520103................................................    1.3291   21.23
520107................................................    1.2651   20.54
520109................................................    1.0080   18.63
520110................................................    1.2429   20.03
520111................................................    1.0771   17.24
520112................................................    1.1370   18.18
520113................................................    1.2753   20.59
520114................................................    1.0715   17.38
520115................................................    1.2443   17.38
520116................................................    1.2746   18.57
520117................................................    1.0104   17.42
520118................................................    0.9267   12.44
520120................................................    0.9639   15.62
520121................................................    0.9809   17.58
520122................................................    0.9984   16.76
520123................................................    0.9687   17.41
520124................................................    1.0565   16.39
520130................................................    1.0658   14.49
520131................................................    1.0212   18.80
520132................................................    1.2099   17.28
520134................................................    1.1056   17.61
520135................................................    0.9696   14.47
520136*...............................................    1.5145   19.85
520138................................................    1.8811   20.56
520139................................................    1.2600   21.28
520140................................................    1.6657   20.99
520141................................................  ........   16.95
520142................................................    0.8561   17.70
520144................................................    1.0159   16.62
520145................................................    0.9104   17.24
520146................................................    1.0606   15.73
520148................................................    1.1740   16.93
520149................................................    0.8682   13.30
520151................................................    1.0569   18.08
520152................................................    1.1284   21.33
520153................................................    0.9014   15.45
520154................................................    1.1279   17.92
520156................................................    1.1295   19.84
520157................................................    1.1386   17.28
520159................................................    0.9313   18.74
520160................................................    1.7788   18.84
520161................................................    0.9970   18.57
520170................................................    1.1959   22.45
520171................................................    0.9550   15.73
520173................................................    1.1310   19.81
520177................................................    1.7167   21.29
520178................................................    1.0405   17.04
520187................................................    0.6853  ......
530002................................................    1.1871   17.59
530003................................................    0.8651   15.78
530004................................................    0.9408   16.19
530005................................................    1.1117   15.15
530006................................................    1.1073   19.34
530007................................................    1.0694   18.06
530008................................................    1.2168   19.71
530009................................................    0.9868   19.45
530010................................................    1.2449   18.93
530011................................................    1.1582   17.44
530012................................................    1.6193   19.48
530014................................................    1.4152   17.32
530015................................................    1.2824   22.65
530016................................................    1.2295   17.71
530017................................................    0.9391   13.71
530018................................................    0.9886   17.87
530019................................................    0.9196   16.76
530022................................................    1.1517   17.88
530023................................................    0.8312   20.75
530025................................................    1.3777   20.32
530026................................................    1.1298   18.92
530027................................................    0.8284   29.77
530029................................................    1.0012   17.97
530031................................................    0.8249   13.38

[[Page 24793]]

 
530032................................................    0.9898   20.21
------------------------------------------------------------------------


 Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) -
                             for Urban Areas
------------------------------------------------------------------------
                                                        Wage
          Urban area (constituent counties)             index      GAF
------------------------------------------------------------------------
0040  Abilene, TX...................................    0.8269    0.8780
  Taylor, TX
0060  Aguadilla, PR.................................    0.4559    0.5840
  Aguada, PR
  Aguadilla, PR
  Moca, PR
0080  Akron, OH.....................................    1.0277    1.0189
  Portage, OH
  Summit, OH
0120  \2\ Albany, GA................................    0.8189    0.8721
  Dougherty, GA
  Lee, GA
0160  \2\ Albany-Schenectady-Troy, NY...............    0.8633    0.9042
  Albany, NY
  Montgomery, NY
  Rensselaer, NY
  Saratoga, NY
  Schenectady, NY
  Schoharie, NY
0200  \2\ Albuquerque, NM...........................    0.8613    0.9028
  Bernalillo, NM
  Sandoval, NM
  Valencia, NM
0220  Alexandria, LA................................    0.7988    0.8574
  Rapides, LA
0240  Allentown-Bethlehem-Easton, PA................    0.9754    0.9831
  Carbon, PA
  Lehigh, PA
  Northampton, PA
0280  Altoona, PA...................................    0.9422    0.9600
  Blair, PA
0320  Amarillo, TX..................................    0.8150    0.8693
  Potter, TX
  Randall, TX
0380  Anchorage, AK.................................    1.3143    1.2058
  Anchorage, AK
0440  Ann Arbor, MI.................................    1.1565    1.1047
  Lenawee, MI
  Livingston, MI
  Washtenaw, MI
0450  Anniston, AL..................................    0.8548    0.8981
  Calhoun, AL
0460  Appleton-Oshkosh-Neenah, WI...................    0.8944    0.9264
  Calumet, WI
  Outagamie, WI
  Winnebago, WI
0470  Arecibo, PR...................................    0.4737    0.5995
  Arecibo, PR
  Camuy, PR
  Hatillo, PR
0480  Asheville, NC.................................    0.8978    0.9288
  Buncombe, NC
  Madison, NC
0500  Athens, GA....................................    0.9556    0.9694
  Clarke, GA
  Madison, GA
  Oconee, GA
0520  \1\ Atlanta, GA...............................    1.0119    1.0081
  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.........................    1.1076    1.0725
  Atlantic, NJ
  Cape May, NJ
0600  Augusta-Aiken, GA-SC..........................    0.9117    0.9387
  Columbia, GA
  McDuffie, GA
  Richmond, GA
  Aiken, SC
  Edgefield, SC
0640  \2\ Austin-San Marcos, TX.....................    0.9511    0.9663
  Bastrop, TX
  Caldwell, TX
  Hays, TX
  Travis, TX
  Williamson, TX
0680  \2\ Bakersfield, CA...........................    1.0153    1.0105
  Kern, CA
0720  \1\ Baltimore, MD.............................    1.0176    1.0120
  Anne Arundel, MD
  Baltimore, MD
  Baltimore City, MD
  Carroll, MD
  Harford, MD
  Howard, MD
  Queen Anne's, MD
0733  Bangor, ME....................................    0.9706    0.9798
  Penobscot, ME
0743  Barnstable-Yarmouth, MA.......................    1.3013    1.1976
  Barnstable, MA
0760  Baton Rouge, LA...............................    0.8796    0.9159
  Ascension, LA
  East Baton Rouge, LA
  Livingston, LA
  West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX......................    0.8555    0.8986
  Hardin, TX
  Jefferson, TX
  Orange, TX
0860  Bellingham, WA................................    1.1509    1.1010
  Whatcom, WA
0870  \2\ Benton Harbor, MI.........................    0.8904    0.9236
  Berrien, MI
0875  \1\ Bergen-Passaic, NJ........................    1.1861    1.1240
  Bergen, NJ
  Passaic, NJ
0880  Billings, MT..................................    1.1802    1.1201
  Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS................    0.8030    0.8605
  Hancock, MS
  Harrison, MS
  Jackson, MS
0960  Binghamton, NY................................    0.8701    0.9091
  Broome, NY
  Tioga, NY
1000  Birmingham, AL................................    0.9010    0.9311
  Blount, AL
  Jefferson, AL
  St. Clair, AL
  Shelby, AL
1010  Bismarck, ND..................................    0.7973    0.8563
  Burleigh, ND
  Morton, ND
1020  Bloomington, IN...............................    0.8680    0.9076
  Monroe, IN
1040  Bloomington-Normal, IL........................    0.9084    0.9363
  McLean, IL
1080  Boise City, ID................................    0.9178    0.9430
  Ada, ID
  Canyon, ID
1123  \1\ Boston-Worcester-Lawrence-Lowell-Brockton,    1.1247    1.0838
 MA-NH..............................................
  Bristol, MA
  Essex, MA
  Middlesex, MA
  Norfolk, MA
  Plymouth, MA
  Suffolk, MA
  Worcester, MA
  Hillsborough, NH
  Merrimack, NH
  Rockingham, NH
  Strafford, NH

[[Page 24794]]

 
1125  Boulder-Longmont, CO..........................    1.0045    1.0031
  Boulder, CO
1145   Brazoria, TX.................................    0.8592    0.9013
  Brazoria, TX
1150  Bremerton, WA.................................    1.1122    1.0755
  Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX..........    0.9243    0.9475
  Cameron, TX
1260  Bryan-College Station, TX.....................    0.8453    0.8913
  Brazos, TX
1280  \1\ Buffalo-Niagara Falls, NY.................    0.9586    0.9715
  Erie, NY
  Niagara, NY
1303  Burlington, VT................................    1.0455    1.0309
  Chittenden, VT
  Franklin, VT
  Grand Isle, VT
1310  Caguas, PR....................................    0.4555    0.5836
  Caguas, PR
  Cayey, PR
  Cidra, PR
  Gurabo, PR
  San Lorenzo, PR
1320  Canton-Massillon, OH..........................    0.8722    0.9106
  Carroll, OH
  Stark, OH
1350  Casper, WY....................................    0.9292    0.9510
  Natrona, WY
1360  Cedar Rapids, IA..............................    0.9110    0.9382
  Linn, IA
1400  Champaign-Urbana, IL..........................    0.9255    0.9484
  Champaign, IL
1440  Charleston-North Charleston, SC...............    0.8997    0.9302
  Berkeley, SC
  Charleston, SC
  Dorchester, SC
1480  Charleston, WV................................    0.9187    0.9436
  Kanawha, WV
  Putnam, WV
1520  \1\ Charlotte-Gastonia-Rock Hill, NC-SC.......    0.9522    0.9670
  Cabarrus, NC
  Gaston, NC
  Lincoln, NC
  Mecklenburg, NC
  Rowan, NC
  Stanly, NC
  Union, NC
  York, SC
1540  Charlottesville, VA...........................    1.0681    1.0461
  Albemarle, VA
  Charlottesville City, VA
  Fluvanna, VA
  Greene, VA
1560  Chattanooga, TN-GA............................    0.9892    0.9926
  Catoosa, GA
  Dade, GA
  Walker, GA
  Hamilton, TN
  Marion, TN
1580  \2\ Cheyenne, WY..............................    0.8891    0.9227
  Laramie, WY
1600  \1\ Chicago, IL...............................    1.0858    1.0580
  Cook, IL
  DeKalb, IL
  DuPage, IL
  Grundy, IL
  Kane, IL
  Kendall, IL
  Lake, IL
  McHenry, IL
  Will, IL
1620  Chico-Paradise, CA............................    1.0381    1.0259
  Butte, CA
1640  \1\ Cincinnati, OH-KY-IN......................    0.9477    0.9639
  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...............    0.8413    0.8884
  Christian, KY
  Montgomery, TN
1680  \1\ Cleveland-Lorain-Elyria, OH...............    0.9724    0.9810
  Ashtabula, OH
  Cuyahoga, OH
  Geauga, OH
  Lake, OH
  Lorain, OH
  Medina, OH
1720  Colorado Springs, CO..........................    0.9311    0.9523
  El Paso, CO
1740  Columbia, MO..................................    0.8982    0.9291
  Boone, MO
1760  Columbia, SC..................................    0.9452    0.9621
  Lexington, SC
  Richland, SC
1800  Columbus, GA-AL...............................    0.8565    0.8994
  Russell, AL
  Chattahoochee, GA
  Harris, GA
  Muscogee, GA
1840  \1\ Columbus, OH..............................    0.9802    0.9864
  Delaware, OH
  Fairfield, OH
  Franklin, OH
  Licking, OH
  Madison, OH
  Pickaway, OH
1880  Corpus Christi, TX............................    0.9318    0.9528
  Nueces, TX
  San Patricio, TX
1900  \2\ Cumberland, MD-WV (Maryland Hospitals)....    0.9096    0.9372
  Allegany, MD
  Mineral, WV
1900  Cumberland, MD-WV (West Virginia Hospitals)...    0.8890    0.9226
  Allegany, MD
  Mineral, WV
1920  \1\ Dallas, TX................................    0.9230    0.9466
  Collin, TX
  Dallas, TX
  Denton, TX
  Ellis, TX
  Henderson, TX
  Hunt, TX
  Kaufman, TX
  Rockwall, TX
1950  Danville, VA..................................    0.9153    0.9412
  Danville City, VA
  Pittsylvania, VA
1960  Davenport-Moline-Rock Island, IA-IL...........    0.8795    0.9158
  Scott, IA
  Henry, IL
  Rock Island, IL
2000  Dayton-Springfield, OH........................    0.9388    0.9577
  Clark, OH
  Greene, OH
  Miami, OH
  Montgomery, OH
2020  \2\ Daytona Beach, FL.........................    0.9074    0.9356
  Flagler, FL
  Volusia, FL
2030  Decatur, AL...................................    0.9983    0.9988
  Lawrence, AL
  Morgan, AL
2040  Decatur, IL...................................    0.8413    0.8884
  Macon, IL
2080  \1\ Denver, CO................................    1.0247    1.0168
  Adams, CO
  Arapahoe, CO
  Denver, CO
  Douglas, CO
  Jefferson, CO
2120  Des Moines, IA................................    0.8849    0.9197
  Dallas, IA
  Polk, IA
  Warren, IA
2160  \1\ Detroit, MI...............................    1.0463    1.0315
  Lapeer, MI

[[Page 24795]]

 
  Macomb, MI
  Monroe, MI
  Oakland, MI
  St. Clair, MI
  Wayne, MI
2180  Dothan, AL....................................    0.7916    0.8521
  Dale, AL
  Houston, AL
2190  Dover, DE.....................................    0.9426    0.9603
  Kent, DE
2200  Dubuque, IA...................................    0.8606    0.9023
  Dubuque, IA
2240  Duluth-Superior, MN-WI........................    1.0278    1.0190
  St. Louis, MN
  Douglas, WI
2281  Dutchess County, NY...........................    0.9837    0.9888
  Dutchess, NY
2290  Eau Claire, WI................................    0.9049    0.9339
  Chippewa, WI
  Eau Claire, WI
2320  El Paso, TX...................................    0.8983    0.9292
  El Paso, TX
2330  Elkhart-Goshen, IN............................    0.9142    0.9404
  Elkhart, IN
2335  \2\ Elmira, NY................................    0.8633    0.9042
  Chemung, NY
2340  Enid, OK......................................    0.8034    0.8608
  Garfield, OK
2360  Erie, PA......................................    0.9078    0.9359
  Erie, PA
2400  Eugene-Springfield, OR........................    1.0761    1.0515
  Lane, OR
2440  \2\ Evansville-Henderson, IN-KY (IN Hospitals)    0.8480    0.8932
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2440  Evansville-Henderson, IN-KY (KY Hospital).....    0.8380    0.8860
  Posey, IN
  Vanderburgh, IN
  Warrick, IN
  Henderson, KY
2520  Fargo-Moorhead, ND-MN.........................    0.8707    0.9095
  Clay, MN
  Cass, ND
2560  Fayetteville, NC..............................    0.8673    0.9071
  Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR............    0.7852    0.8474
  Benton, AR
  Washington, AR
2620  Flagstaff, AZ-UT..............................    1.0453    1.0308
  Coconino, AZ
  Kane, UT
2640  Flint, MI.....................................    1.1132    1.0762
  Genesee, MI
2650  Florence, AL..................................    0.8007    0.8588
  Colbert, AL
  Lauderdale, AL
2655  Florence, SC..................................    0.8706    0.9095
  Florence, SC
2670  Fort Collins-Loveland, CO.....................    1.0406    1.0276
  Larimer, CO
2680  \1\ Ft. Lauderdale, FL........................    1.0239    1.0163
  Broward, FL
2700  \2\ Fort Myers-Cape Coral, FL.................    0.9074    0.9356
  Lee, FL
2710  Fort Pierce-Port St. Lucie, FL................    1.0240    1.0164
  Martin, FL
  St. Lucie, FL
2720  Fort Smith, AR-OK.............................    0.7923    0.8526
  Crawford, AR
  Sebastian, AR
  Sequoyah, OK
2750  \2\ Fort Walton Beach, FL.....................    0.9074    0.9356
  Okaloosa, FL
2760  Fort Wayne, IN................................    0.8941    0.9262
  Adams, IN
  Allen, IN
  De Kalb, IN
  Huntington, IN
  Wells, IN
  Whitley, IN
2800  \1\ Forth Worth-Arlington, TX.................    0.9003    0.9306
  Hood, TX
  Johnson, TX
  Parker, TX
  Tarrant, TX
2840  Fresno, CA....................................    1.0371    1.0253
  Fresno, CA
  Madera, CA
2880  Gadsden, AL...................................    0.8842    0.9192
  Etowah, AL
2900  Gainesville, FL...............................    1.0181    1.0124
  Alachua, FL
2920  Galveston-Texas City, TX......................    0.9569    0.9703
  Galveston, TX
2960  Gary, IN......................................    0.9449    0.9619
  Lake, IN
  Porter, IN
2975  Glens Falls, NY...............................    0.8693    0.9085
  Warren, NY
  Washington, NY
2980  Goldsboro, NC.................................    0.8418    0.8888
  Wayne, NC
2985  Grand Forks, ND-MN............................    0.9190    0.9438
  Polk, MN
  Grand Forks, ND
2995  Grand Junction, CO............................    0.9291    0.9509
  Mesa, CO
3000  \1\ Grand Rapids-Muskegon-Holland, MI.........    1.0169    1.0115
  Allegan, MI
  Kent, MI
  Muskegon, MI
  Ottawa, MI
3040  Great Falls, MT...............................    1.0626    1.0425
  Cascade, MT
3060  Greeley, CO...................................    0.9449    0.9619
  Weld, CO
3080  Green Bay, WI.................................    0.9305    0.9519
  Brown, WI
3120  \1\ Greensboro-Winston-Salem-High Point, NC...    0.9122    0.9390
  Alamance, NC
  Davidson, NC
  Davie, NC
  Forsyth, NC
  Guilford, NC
  Randolph, NC
  Stokes, NC
  Yadkin, NC
3150  Greenville, NC................................    0.9570    0.9704
  Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC...........    0.9199    0.9444
  Anderson, SC
  Cherokee, SC
  Greenville, SC
  Pickens, SC
  Spartanburg, SC
3180  \2\ Hagerstown, MD............................    0.9096    0.9372
  Washington, MD
3200  Hamilton-Middletown, OH.......................    0.9080    0.9360
  Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA...............    0.9896    0.9929
  Cumberland, PA
  Dauphin, PA
  Lebanon, PA
  Perry, PA
3283  \1\ \2\ Hartford, CT..........................    1.2692    1.1773
  Hartford, CT
  Litchfield, CT
  Middlesex, CT
  Tolland, CT
3285  Hattiesburg, MS...............................    0.7453    0.8177
  Forrest, MS
  Lamar, MS
3290  Hickory-Morganton-Lenoir, NC..................    0.9255    0.9484
  Alexander, NC
  Burke, NC
  Caldwell, NC
  Catawba, NC
3320  Honolulu, HI..................................    1.1600    1.1070

[[Page 24796]]

 
  Honolulu, HI
3350  Houma, LA.....................................    0.7916    0.8521
  Lafourche, LA
  Terrebonne, LA
3360  \1\ Houston, TX...............................    0.9286    0.9505
  Chambers, TX
  Fort Bend, TX
  Harris, TX
  Liberty, TX
  Montgomery, TX
  Waller, TX
3400  Huntington-Ashland, WV-KY-OH..................    0.9851    0.9898
  Boyd, KY
  Carter, KY
  Greenup, KY
  Lawrence, OH
  Cabell, WV
  Wayne, WV
3440  Huntsville, AL................................    0.8912    0.9242
  Limestone, AL
  Madison, AL
3480  \1\ Indianapolis, IN..........................    0.9876    0.9915
  Boone, IN
  Hamilton, IN
  Hancock, IN
  Hendricks, IN
  Johnson, IN
  Madison, IN
  Marion, IN
  Morgan, IN
  Shelby, IN
3500  Iowa City, IA.................................    0.9705    0.9797
  Johnson, IA
3520  Jackson, MI...................................    0.8930    0.9254
  Jackson, MI
3560  Jackson, MS...................................    0.8519    0.8960
  Hinds, MS
  Madison, MS
  Rankin, MS
3580  Jackson, TN...................................    1.0953    1.0643
  Madison, TN
  Chester, TN
3600  \1\ \2\ Jacksonville, FL......................    0.9074    0.9356
  Clay, FL
  Duval, FL
  Nassau, FL
  St. Johns, FL
3605  \2\ Jacksonville, NC..........................    0.8349    0.8838
  Onslow, NC
3610  \2\ Jamestown, NY.............................    0.8633    0.9042
  Chautauqua, NY
3620  Janesville-Beloit, WI.........................    0.9703    0.9796
  Rock, WI
3640  Jersey City, NJ...............................    1.1718    1.1147
  Hudson, NJ
3660  Johnson City-Kingsport-Bristol, TN-VA.........    0.8935    0.9258
  Carter, TN
  Hawkins, TN
  Sullivan, TN
  Unicoi, TN
  Washington, TN
  Bristol City, VA
  Scott, VA
  Washington, VA
3680  \2\ Johnstown, PA.............................    0.8488    0.8938
  Cambria, PA
  Somerset, PA
3700  Jonesboro, AR.................................    0.7324    0.8079
  Craighead, AR
3710  Joplin, MO....................................    0.7756    0.8403
  Jasper, MO
  Newton, MO
3720  Kalamazoo-Battlecreek, MI.....................    1.0095    1.0065
  Calhoun, MI
  Kalamazoo, MI
  Van Buren, MI
3740  Kankakee, IL..................................    0.8349    0.8838
  Kankakee, IL
3760  \1\ Kansas City, KS-MO........................    0.9301    0.9516
  Johnson, KS
  Leavenworth, KS
  Miami, KS
  Wyandotte, KS
  Cass, MO
  Clay, MO
  Clinton, MO
  Jackson, MO
  Lafayette, MO
  Platte, MO
  Ray, MO
3800  \2\ Kenosha, WI...............................    0.8842    0.9192
  Kenosha, WI
3810  Killeen-Temple, TX............................    1.0031    1.0021
  Bell, TX
  Coryell, TX
3840  Knoxville, TN.................................    0.9315    0.9526
  Anderson, TN
  Blount, TN
  Knox, TN
  Loudon, TN
  Sevier, TN
  Union, TN
3850  Kokomo, IN....................................    0.9075    0.9357
  Howard, IN
  Tipton, IN
3870  La Crosse, WI-MN..............................    0.9024    0.9321
  Houston, MN
  La Crosse, WI
3880  Lafayette, LA.................................    0.8160    0.8700
  Acadia, LA
  Lafayette, LA
  St. Landry, LA
  St. Martin, LA
3920  Lafayette, IN.................................    0.8898    0.9232
  Clinton, IN
  Tippecanoe, IN
3960  Lake Charles, LA..............................    0.7901    0.8510
  Calcasieu, LA
3980  \2\ Lakeland-Winter Haven, FL.................    0.9074    0.9356
  Polk, FL
4000  Lancaster, PA.................................    0.8944    0.9264
  Lancaster, PA
4040  Lansing-East Lansing, MI......................    1.0091    1.0062
  Clinton, MI
  Eaton, MI
  Ingham, MI
4080  Laredo, TX....................................    0.8407    0.8880
  Webb, TX
4100  \2\ Las Cruces, NM............................    0.8613    0.9028
  Dona Ana, NM
4120  \1\ Las Vegas, NV-AZ..........................    1.1182    1.0795
  Mohave, AZ
  Clark, NV
  Nye, NV
4150  Lawrence, KS..................................    0.8306    0.8806
  Douglas, KS
4200  Lawton, OK....................................    0.8475    0.8929
  Comanche, OK
4243  Lewiston-Auburn, ME...........................    0.8971    0.9283
  Androscoggin, ME
4280  Lexington, KY.................................    0.8683    0.9078
  Bourbon, KY
  Clark, KY
  Fayette, KY
  Jessamine, KY
  Madison, KY
  Scott, KY
  Woodford, KY
4320  Lima, OH......................................    0.8995    0.9300
  Allen, OH
  Auglaize, OH
4360  Lincoln, NE...................................    0.9768    0.9841
  Lancaster, NE
4400  Little Rock-North Little Rock, AR.............    0.8698    0.9089
  Faulkner, AR
  Lonoke, AR
  Pulaski, AR
  Saline, AR
4420  Longview-Marshall, TX.........................    0.8828    0.9182
  Gregg, TX
  Harrison, TX
  Upshur, TX
4480  \1\ Los Angeles-Long Beach, CA................    1.1903    1.1267
  Los Angeles, CA
4520  Louisville, KY-IN.............................    0.9296    0.9512
  Clark, IN
  Floyd, IN
  Harrison, IN
  Scott, IN
  Bullitt, KY
  Jefferson, KY
  Oldham, KY
4600  Lubbock, TX...................................    0.8438    0.8902

[[Page 24797]]

 
  Lubbock, TX
4640  Lynchburg, VA.................................    0.9048    0.9338
  Amherst, VA
  Bedford, VA
  Bedford City, VA
  Campbell, VA
  Lynchburg City, VA
4680  Macon, GA.....................................    0.8615    0.9029
  Bibb, GA
  Houston, GA
  Jones, GA
  Peach, GA
  Twiggs, GA
4720  Madison, WI...................................    1.0096    1.0066
  Dane, WI
4800  \2\ Mansfield, OH.............................    0.8722    0.9106
  Crawford, OH
  Richland, OH
4840  Mayaguez, PR..................................    0.4862    0.6103
  Anasco, PR
  Cabo Rojo, PR
  Hormigueros, PR
  Mayaguez, PR
  Sabana Grande, PR
  San German, PR
4880  McAllen-Edinburg-Mission, TX..................    0.8152    0.8694
  Hidalgo, TX
4890   Medford-Ashland, OR..........................    1.0600    1.0407
  Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.............    0.9390    0.9578
  Brevard, Fl
4920  \1\ Memphis, TN-AR-MS.........................    0.8070    0.8634
  Crittenden, AR
  DeSoto, MS
  Fayette, TN
  Shelby, TN
  Tipton, TN
4940  Merced, CA....................................
  Merced, CA                                            1.0615    1.0417
5000  \1\ Miami, FL.................................    1.0314    1.0214
  Dade, FL
5015  \1\ Middlesex-Somerset-Hunterdon, NJ..........    1.1028    1.0693
  Hunterdon, NJ
  Middlesex, NJ
  Somerset, NJ
5080  \1\ Milwaukee-Waukesha, WI....................    0.9840    0.9890
  Milwaukee, WI
  Ozaukee, WI
  Washington, WI
  Waukesha, WI
5120  \1\ Minneapolis-St. Paul, MN-WI...............    1.0630    1.0427
  Anoka, MN
  Carver, MN
  Chicago, MN
  Dakota, MN
  Hennepin, MN
  Isanti, MN
  Ramsey, MN
  Scott, MN
  Sherburne, MN
  Washington, MN
  Wright, MN
  Pierce, WI
  St. Croix, WI
5140  Missoula, MT..................................    0.9281    0.9502
  Missoula, MT
5160  Mobile, AL....................................    0.8301    0.8803
  Baldwin, AL
  Mobile, AL
5170  Modesto, CA...................................    1.0183    1.0125
  Stanislaus, CA
5190  \1\ Monmouth-Ocean, NJ........................    1.1371    1.0920
  Monmouth, NJ
  Ocean, NJ
5200  Monroe, LA....................................    0.8304    0.8805
  Ouachita, LA
5240  \2\ Montgomery, AL............................    0.7542    0.8243
  Autauga, AL
  Elmore, AL
  Montgomery, AL
5280  Muncie, IN....................................    1.0869    1.0587
  Delaware, IN
5330  Myrtle Beach, SC..............................    0.8647    0.9052
  Horry, SC
5345  Naples, FL....................................    1.0234    1.0160
  Collier, FL
5360  \1\ Nashville, TN.............................    0.9140    0.9403
  Cheatham, TN
  Davidson, TN
  Dickson, TN
  Robertson, TN
  Rutherford TN
  Sumner, TN
  Williamson, TN
  Wilson, TN
5380  \1\ Nassau-Suffolk, NY........................    1.3274    1.2140
  Nassau, NY
  Suffolk, NY
5483  \1\ \2\ New Haven-Bridgeport-Stamford-            1.2692    1.1773
 Waterbury-Danbury, CT..............................
  Fairfield, CT
  New Haven, CT
5523  \2\ New London-Norwich, CT....................    1.2692    1.1773
  New London, CT
5560  \1\ New Orleans, LA...........................    0.9073    0.9356
  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..............................    1.4302    1.2777
  Bronx, NY
  Kings, NY
  New York, NY
  Putnam, NY
  Queens, NY
  Richmond, NY
  Rockland, NY
  Westchester, NY
5640  \1\ Newark, NJ................................    1.0873    1.0590
  Essex, NJ
  Morris, NJ
  Sussex, NJ
  Union, NJ
  Warren, NJ
5660  Newburgh, NY-PA...............................    1.1019    1.0687
  Orange, NY
  Pike, PA
5720  \1\ Norfolk-Virginia Beach-Newport News, VA-NC    0.8378    0.8859
  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...............................    1.5199    1.3320
  Alameda, CA
  Contra Costa, CA
5790  Ocala, FL.....................................    0.9712    0.9802
  Marion, FL
5800  Odessa-Midland, TX............................    0.8016    0.8595
  Ector, TX
  Midland, TX
5880  \1\ Oklahoma City, OK.........................    0.8705    0.9094
  Canadian, OK
  Cleveland, OK
  Logan, OK
  McClain, OK
  Oklahoma, OK
  Pottawatomie, OK
5910   Olympia, WA..................................    1.2750    1.1810
  Thurston, WA
5920  Omaha, NE-IA..................................    1.0722    1.0489
  Pottawattamie, IA
  Cass, NE

[[Page 24798]]

 
  Douglas, NE
  Sarpy, NE
  Washington, NE
5945  \1\ Orange County, CA.........................    1.1539    1.1030
  Orange, CA
5960  \1\ Orlando, FL...............................    0.9997    0.9998
  Lake, FL
  Orange, FL
  Osceola, FL
  Seminole, FL
5990  \2\ Owensboro, KY.............................    0.8129    0.8677
  Daviess, KY
6015   Panama City, FL..............................    0.9266    0.9491
  Bay, FL
6020  Parkersburg-Marietta, WV-OH (West Virginia        0.8500    0.8947
 Hospitals).........................................
  Washington, OH
  Wood, WV
6020  \2\ Parkersburg-Marietta, WV-OH (Ohio             0.8722    0.9106
 Hospitals).........................................
  Washington, OH
  Wood, WV
6080  \2\ Pensacola, FL.............................    0.9074    0.9356
  Escambia, FL
  Santa Rosa, FL
6120  Peoria-Pekin, IL..............................    0.8495    0.8943
  Peoria, IL
  Tazewell, IL
  Woodford, IL
6160  \1\ Philadelphia, PA-NJ.......................    1.1077    1.0726
  Burlington, NJ
  Camden, NJ
  Gloucester, NJ
  Salem, NJ
  Bucks, PA
  Chester, PA
  Delaware, PA
  Montgomery, PA
  Philadelphia, PA
6200  \1\ Phoenix-Mesa, AZ..........................    0.9546    0.9687
  Maricopa, AZ
  Pinal, AZ
6240  Pine Bluff, AR................................    0.7689    0.8353
  Jefferson, AR
6280  \1\ Pittsburgh, PA............................    0.9537    0.9681
  Allegheny, PA
  Beaver, PA
  Butler, PA
  Fayette, PA
  Washington, PA
  Westmoreland, PA
6323  Pittsfield, MA................................    1.0767    1.0519
  Berkshire, MA
6340  Pocatello, ID.................................    0.9068    0.9352
  Bannock, ID
6360  Ponce, PR.....................................    0.5026    0.6243
  Guayanilla, PR
  Juana Diaz, PR
  Penuelas, PR
  Ponce, PR
  Villalba, PR
  Yauco, PR
6403  Portland, ME..................................    0.9552    0.9691
  Cumberland, ME
  Sagadahoc, ME
  York, ME
6440  \1\ Portland-Vancouver, OR-WA.................    1.1091    1.0735
  Clackamas, OR
  Columbia, OR
  Multnomah, OR
  Washington, OR
  Yamhill, OR
  Clark, WA
6483  \1\ Providence-Warwick-Pawtucket, RI..........    1.0789    1.0534
  Bristol, RI
  Kent, RI
  Newport, RI
  Providence, RI
  Washington, RI
6520  Provo-Orem, UT................................    0.9786    0.9853
  Utah, UT
6560  Pueblo, CO....................................    0.8943    0.9264
  Pueblo, CO
6580  \2\ Punta Gorda, FL...........................    0.9074    0.9356
  Charlotte, FL
6600  Racine, WI....................................    0.9310    0.9522
  Racine, WI
6640  \1\ Raleigh-Durham-Chapel Hill, NC............    0.9631    0.9746
  Chatham, NC
  Durham, NC
  Franklin, NC
  Johnston, NC
  Orange, NC
  Wake, NC
6660  Rapid City, SD................................    0.8449    0.8910
  Pennington, SD
6680  Reading, PA...................................    0.9526    0.9673
  Berks, PA
6690  Redding, CA...................................    1.1392    1.0934
  Shasta, CA
6720  Reno, NV......................................    1.0763    1.0516
  Washoe, NV
6740  Richland-Kennewick-Pasco, WA..................    1.1338    1.0898
  Benton, WA
  Franklin, WA
6760  Richmond-Petersburg, VA.......................    1.0053    1.0036
  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..............    1.0622    1.0422
  Riverside, CA
  San Bernardino, CA
6800  Roanoke, VA...................................    0.8224    0.8747
  Botetourt, VA
  Roanoke, VA
  Roanoke City, VA
  Salem City, VA
6820  Rochester, MN.................................    1.1056    1.0712
  Olmsted, MN
6840  \1\ Rochester, NY.............................    0.9448    0.9619
  Genesee, NY
  Livingston, NY
  Monroe, NY
  Ontario, NY
  Orleans, NY
  Wayne, NY
6880  Rockford, IL..................................    0.8861    0.9205
  Boone, IL
  Ogle, IL
  Winnebago, IL
6895  Rocky Mount, NC...............................    0.8823    0.9178
  Edgecombe, NC
  Nash, NC
6920  \1\ Sacramento, CA............................    1.2482    1.1640
  El Dorado, CA
  Placer, CA
  Sacramento, CA
6960  Saginaw-Bay City-Midland, MI..................    0.9422    0.9600
  Bay, MI
  Midland, MI
  Saginaw, MI
6980  St. Cloud, MN.................................    0.9650    0.9759
  Benton, MN
  Stearns, MN
7000  St. Joseph, MO................................    0.8836    0.9187
  Andrew, MO
  Buchanan, MO
7040  \1\ St. Louis, MO-IL..........................    0.9186    0.9435
  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  \2\ Salem, OR.................................    1.0071    1.0049

[[Page 24799]]

 
  Marion, OR
  Polk, OR
7120  Salinas, CA...................................    1.4706    1.3023
  Monterey, CA
7160  \1\ Salt Lake City-Ogden, UT..................    0.9884    0.9920
  Davis, UT
  Salt Lake, UT
  Weber, UT
7200  San Angelo, TX................................    0.7870    0.8487
  Tom Green, TX
7240  \1\ San Antonio, TX...........................    0.8271    0.8781
  Bexar, TX
  Comal, TX
  Guadalupe, TX
  Wilson, TX
7320  \1\ San Diego, CA.............................    1.1943    1.1293
  San Diego, CA
7360  \1\ San Francisco, CA.........................    1.3976    1.2576
  Marin, CA
  San Francisco, CA
  San Mateo, CA
7400  \1\ San Jose, CA..............................    1.3714    1.2415
  Santa Clara, CA
7440  \1\ San Juan-Bayamon, PR......................    0.4740    0.5998
  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....    1.0576    1.0391
  San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA..........    1.0927    1.0626
  Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA....................    1.4068    1.2633
  Santa Cruz, CA
7490  Santa Fe, NM..................................    0.9115    0.9385
  Los Alamos, NM
  Santa Fe, NM
7500   Santa Rosa, CA...............................    1.3127    1.2048
  Sonoma, CA
7510  Sarasota-Bradenton, FL........................    0.9928    0.9951
  Manatee, FL
  Sarasota, FL
7520  Savannah, GA..................................    0.9892    0.9926
  Bryan, GA
  Chatham, GA
  Effingham, GA
7560  \2\ Scranton-Wilkes-Barre-Hazleton, PA........    0.8488    0.8938
  Columbia, PA
  Lackawanna, PA
  Luzerne, PA
  Wyoming, PA
7600  \1\ Seattle-Bellevue-Everett, WA..............    1.1390    1.0932
  Island, WA
  King, WA
  Snohomish, WA
7610  \2\ Sharon, PA................................    0.8488    0.8938
  Mercer, PA
7620  \2\ Sheboygan, WI.............................    0.8842    0.9192
  Sheboygan, WI
7640  Sherman-Denison, TX...........................    0.9213    0.9454
  Grayson, TX
7680   Shreveport-Bossier City, LA..................    0.9142    0.9404
  Bossier, LA
  Caddo, LA
  Webster, LA
7720  Sioux City, IA-NE.............................    0.8051    0.8620
  Woodbury, IA
  Dakota, NE
7760  Sioux Falls, SD...............................    0.8778    0.9146
  Lincoln, SD
  Minnehaha, SD
7800  South Bend, IN................................    0.9893    0.9927
  St. Joseph, IN
7840  Spokane, WA...................................    1.0891    1.0602
  Spokane, WA
7880  Springfield, IL...............................    0.8772    0.9142
  Menard, IL
  Sangamon, IL
7920  Springfield, MO...............................    0.8003    0.8585
  Christian, MO
  Greene, MO
  Webster, MO
8003  Springfield, MA...............................    0.9914    0.9941
  Hampden, MA
  Hampshire, MA
8050  State College, PA.............................    0.9249    0.9479
  Centre, PA
8080  \2\ Steubenville-Weirton, OH-WV (Ohio             0.8722    0.9106
 Hospitals).........................................
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8080  Steubenville-Weirton, OH-WV (West Virginia        0.8702    0.9092
 Hospitals).........................................
  Jefferson, OH
  Brooke, WV
  Hancock, WV
8120  Stockton-Lodi, CA.............................    1.0623    1.0423
  San Joaquin, CA
8140  \2\ Sumter, SC................................    0.8541    0.8976
  Sumter, SC
8160  Syracuse, NY..................................    0.9527    0.9674
  Cayuga, NY
  Madison, NY
  Onondaga, NY
  Oswego, NY
8200  Tacoma, WA....................................    1.1755    1.1171
  Pierce, WA
8240  \2\ Tallahassee, FL...........................    0.9074    0.9356
  Gadsden, FL
  Leon, FL
8280  \1\ Tampa-St. Petersburg-Clearwater, FL.......    0.9260    0.9487
  Hernando, FL
  Hillsborough, FL
  Pasco, FL
  Pinellas, FL
8320  Terre Haute, IN...............................    0.8673    0.9071
  Clay, IN
  Vermillion, IN
  Vigo, IN
8360  Texarkana, AR-Texarkana, TX...................    0.8206    0.8734
  Miller, AR
  Bowie, TX
8400  Toledo, OH....................................    0.9810    0.9870
  Fulton, OH
  Lucas, OH
  Wood, OH
8440  Topeka, KS....................................    0.9195    0.9441
  Shawnee, KS
8480  Trenton, NJ...................................    1.0051    1.0035
  Mercer, NJ
8520  Tucson, AZ....................................    0.8831    0.9184
  Pima, AZ
8560  Tulsa, OK.....................................    0.7852    0.8474
  Creek, OK
  Osage, OK
  Rogers, OK
  Tulsa, OK
  Wagoner, OK

[[Page 24800]]

 
8600  Tuscaloosa, AL................................    0.7994    0.8579
  Tuscaloosa, AL
8640  Tyler, TX.....................................    0.8572    0.8999
  Smith, TX
8680  \2\ Utica-Rome, NY............................    0.8633    0.9042
  Herkimer, NY
  Oneida, NY
8720  Vallejo-Fairfield-Napa, CA....................    1.2783    1.1831
  Napa, CA
  Solano, CA
8735  Ventura, CA...................................    1.0983    1.0663
  Ventura, CA
8750  Victoria, TX..................................    0.8062    0.8628
  Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ..............    1.0623    1.0423
  Cumberland, NJ
8780  Visalia-Tulare-Porterville, CA................    1.0409    1.0278
  Tulare, CA
8800  Waco, TX......................................    0.7561    0.8258
  McLennan, TX
8840  \1\ Washington, DC-MD-VA-WV...................    1.1118    1.0753
  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......................    0.9039    0.9332
  Black Hawk, IA
8940  Wausau, WI....................................    0.9545    0.9686
  Marathon, WI
8960  \1\ West Palm Beach-Boca Raton, FL............    1.0167    1.0114
  Palm Beach, FL
9000  \2\ Wheeling, WV-OH (West Virginia Hospitals).    0.8206    0.8734
  Belmont, OH
  Marshall, WV
  Ohio, WV
9000  \2\ Wheeling, WV-OH (Ohio Hospitals)..........    0.8722    0.9106
  Belmont, OH
  Marshall, WV
  Ohio, WV
9040  Wichita, KS...................................    0.9117    0.9387
  Butler, KS
  Harvey, KS
  Sedgwick, KS
9080  Wichita Falls, TX.............................    0.7730    0.8384
  Archer, TX
  Wichita, TX
9140  Williamsport, PA..............................    0.8611    0.9027
  Lycoming, PA
9160  Wilmington-Newark, DE-MD......................    1.1388    1.0931
  New Castle, DE
  Cecil, MD
9200  Wilmington, NC................................    0.9962    0.9974
  New Hanover, NC
  Brunswick, NC
9260  \2\ Yakima, WA................................    1.0474    1.0322
  Yakima, WA
9270  Yolo, CA......................................    1.0591    1.0401
  Yolo, CA
9280  York, PA......................................    0.9348    0.9549
  York, PA
9320  Youngstown-Warren, OH.........................    1.0098    1.0067
  Columbiana, OH
  Mahoning, OH
  Trumbull, OH
9340  Yuba City, CA.................................    1.0770    1.0521
  Sutter, CA
  Yuba, CA
9360  Yuma, AZ......................................    1.0024    1.0016
  Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area.
\2\ Hospitals geographically located in the area are assigned the
  statewide rural wage index for FY 2000.


Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                               Rural Areas
------------------------------------------------------------------------
                                                        Wage
                    Nonurban area                       index      GAF
------------------------------------------------------------------------
Alabama.............................................    0.7542    0.8243
Alaska..............................................    1.2181    1.1447
Arizona.............................................    0.8610    0.9026
Arkansas............................................    0.7290    0.8054
California..........................................    1.0153    1.0105
Colorado............................................    0.8852    0.9199
Connecticut.........................................    1.2692    1.1773
Delaware............................................    0.9259    0.9486
Florida.............................................    0.9074    0.9356
Georgia.............................................    0.8189    0.8721
Hawaii..............................................    1.0812    1.0549
Idaho...............................................    0.8715    0.9101
Illinois............................................    0.8121    0.8672
Indiana.............................................    0.8480    0.8932
Iowa................................................    0.8000    0.8583
Kansas..............................................    0.7512    0.8221
Kentucky............................................    0.8129    0.8677
Louisiana...........................................    0.7519    0.8226
Maine...............................................    0.8706    0.9095
Maryland............................................    0.9096    0.9372
Massachusetts.......................................    0.9914    0.9941
Michigan............................................    0.8904    0.9236
Minnesota...........................................    0.8753    0.9128
Mississippi.........................................    0.7453    0.8177
Missouri............................................    0.7701    0.8362
Montana.............................................    0.8528    0.8967
Nebraska............................................    0.8075    0.8638
Nevada..............................................    0.9633    0.9747
New Hampshire.......................................    0.9978    0.9985
New Jersey \1\......................................  ........  ........
New Mexico..........................................    0.8613    0.9028
New York............................................    0.8633    0.9042
North Carolina......................................    0.8349    0.8838
North Dakota........................................    0.7750    0.8398
Ohio................................................    0.8722    0.9106
Oklahoma............................................    0.7345    0.8095
Oregon..............................................    1.0071    1.0049
Pennsylvania........................................    0.8488    0.8938
Puerto Rico.........................................    0.4379    0.5681
Rhode Island \1\....................................  ........  ........
South Carolina......................................    0.8541    0.8976
South Dakota........................................    0.7663    0.8334
Tennessee...........................................    0.7743    0.8393
Texas...............................................    0.7008    0.7839
Utah................................................    0.8219    0.8743
Vermont.............................................    0.9524    0.9672
Virginia............................................    0.7938    0.8537
Washington..........................................    1.0474    1.0322
West Virginia.......................................    0.8206    0.8734
Wisconsin...........................................    0.8842    0.9192
Wyoming.............................................    0.8891    0.9227
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                     Hospitals That are Reclassified
------------------------------------------------------------------------
                                                        Wage
                        Area                            index      GAF
------------------------------------------------------------------------
Abilene, TX.........................................    0.8269    0.8780
Akron, OH...........................................    1.0091    1.0062
Albany, GA..........................................    0.8189    0.8721
Alexandria, LA......................................    0.7988    0.8574
Amarillo, TX........................................    0.8150    0.8693
Anchorage, AK.......................................    1.3143    1.2058
Ann Arbor, MI.......................................    1.1437    1.0963
Atlanta, GA.........................................    1.0119    1.0081
Austin-San Marcos, TX...............................    0.9511    0.9663

[[Page 24801]]

 
Baltimore, MD.......................................    1.0176    1.0120
Baton Rouge, LA.....................................    0.8796    0.9159
Beaumont-Port Arthur, TX............................    0.8555    0.8986
Bergen-Passaic, NJ..................................    1.1861    1.1240
Billings, MT........................................    1.1496    1.1002
Biloxi-Gulfport-Pascagoula, MS......................    0.8030    0.8605
Binghamton, NY......................................    0.8701    0.9091
Birmingham, AL......................................    0.9010    0.9311
Bismarck, ND........................................    0.7973    0.8563
Boise City, ID......................................    0.9178    0.9430
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH....    1.1247    1.0838
Burlington, VT......................................    1.0046    1.0031
Caguas, PR..........................................    0.4555    0.5836
Champaign-Urbana, IL................................    0.9255    0.9484
Charleston-North Charleston, SC.....................    0.8997    0.9302
Charleston, WV......................................    0.8950    0.9268
Charlotte-Gastonia-Rock Hill, NC-SC.................    0.9522    0.9670
Chattanooga, TN-GA..................................    0.9586    0.9715
Chicago, IL.........................................    1.0858    1.0580
Cincinnati, OH-KY-IN................................    0.9477    0.9639
Clarksville-Hopkinsville, TN-KY.....................    0.8413    0.8884
Cleveland-Lorain-Elyria, OH.........................    0.9724    0.9810
Columbia, MO........................................    0.8815    0.9173
Columbia, SC........................................    0.9308    0.9521
Columbus, GA-AL.....................................    0.8379    0.8859
Columbus, OH........................................    0.9660    0.9766
Corpus Christi, TX..................................    0.9172    0.9425
Dallas, TX..........................................    0.9230    0.9466
Danville, VA........................................    0.8795    0.9158
Davenport-Moline-Rock Island,
  IA-IL.............................................    0.8694    0.9086
Dayton-Springfield, OH..............................    0.9284    0.9504
Denver, CO..........................................    1.0247    1.0168
Des Moines, IA......................................    0.8849    0.9197
Dothan, AL..........................................    0.7916    0.8521
Dover, DE...........................................    1.0618    1.0419
Duluth-Superior, MN-WI..............................    1.0278    1.0190
Elkhart-Goshen, IN..................................    0.9142    0.9404
Eugene-Springfield, OR..............................    1.0761    1.0515
Evansville-Henderson, IN-KY.........................    0.8480    0.8932
Fargo-Moorhead, ND-MN (ND and SD Hospitals).........    0.8707    0.9095
Fargo-Moorhead, ND-MN (MN Hospital).................    0.8753    0.9128
Fayetteville, NC....................................    0.8673    0.9071
Flagstaff, AZ-UT....................................    0.9960    0.9973
Fort Collins-Loveland, CO...........................    1.0301    1.0205
Fort Pierce-Port St. Lucie, FL......................    1.0240    1.0164
Fort Smith, AR-OK...................................    0.7774    0.8416
Fort Walton Beach, FL...............................    0.9005    0.9307
Forth Worth-Arlington, TX...........................    0.9003    0.9306
Fresno, CA..........................................    1.0371    1.0253
Gadsden, AL.........................................    0.8842    0.9192
Gainesville, FL.....................................    1.0042    1.0029
Goldsboro, NC.......................................    0.8418    0.8888
Grand Forks, ND-MN..................................    0.9190    0.9438
Grand Rapids-Muskegon-Holland, MI...................    1.0062    1.0042
Great Falls, MT.....................................    1.0626    1.0425
Greeley, CO.........................................    0.9292    0.9510
Green Bay, WI.......................................    0.9305    0.9519
Greensboro-Winston-Salem-High Point, NC.............    0.9122    0.9390
Greenville, NC......................................    0.9313    0.9524
Greenville-Spartanburg-Anderson, SC.................    0.9199    0.9444
Hagerstown, MD......................................    0.8943    0.9264
Harrisburg-Lebanon-Carlisle, PA.....................    0.9787    0.9854
Hartford, CT........................................    1.1220    1.0820
Hickory-Morganton-Lenoir, NC........................    0.9255    0.9484
Honolulu, HI........................................    1.1600    1.1070
Houston, TX.........................................    0.9286    0.9505
Huntington-Ashland, WV-KY-OH........................    0.9563    0.9699
Huntsville, AL......................................    0.8912    0.9242
Indianapolis, IN....................................    0.9876    0.9915
Iowa City, IA.......................................    0.9556    0.9694
Jackson, MS.........................................    0.8519    0.8960
Jackson, TN.........................................    1.0339    1.0231
Jacksonville, FL....................................    0.8993    0.9299
Johnson City-Kingsport-Bristol, TN-VA...............    0.8935    0.9258
Jonesboro, AR.......................................    0.7324    0.8079
Joplin, MO..........................................    0.7756    0.8403
Kalamazoo-Battlecreek, MI...........................    1.0095    1.0065
Kansas City, KS-MO..................................    0.9301    0.9516
Knoxville, TN.......................................    0.9315    0.9526
Kokomo, IN..........................................    0.9075    0.9357
Lafayette, LA.......................................    0.8160    0.8700
Lansing-East Lansing, MI............................    0.9980    0.9986
Las Vegas, NV-AZ....................................    1.1182    1.0795
Lexington, KY.......................................    0.8683    0.9078
Lincoln, NE.........................................    0.9535    0.9679
Little Rock-North Little Rock, AR...................    0.8498    0.8945
Longview-Marshall, TX...............................    0.8618    0.9032
Los Angeles-Long Beach, CA..........................    1.1903    1.1267
Louisville, KY-IN...................................    0.9296    0.9512
Macon, GA...........................................    0.8615    0.9029
Madison, WI.........................................    1.0096    1.0066
Memphis, TN-AR-MS...................................    0.8070    0.8634
Merced, CA..........................................    1.0615    1.0417
Milwaukee-Waukesha, WI..............................    0.9840    0.9890
Minneapolis-St. Paul, MN-WI.........................    1.0630    1.0427
Missoula, MT........................................    0.9281    0.9502
Monmouth-Ocean, NJ..................................    1.0829    1.0561
Monroe, LA..........................................    0.8143    0.8688
Montgomery, AL......................................    0.7542    0.8243
Myrtle Beach, SC....................................    0.8465    0.8922
Nashville, TN.......................................    0.9008    0.9310
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.    1.2692    1.1773
New London-Norwich, CT..............................    1.0860    1.0581
New Orleans, LA.....................................    0.9073    0.9356
New York, NY........................................    1.4302    1.2777
Newark, NJ..........................................    1.0873    1.0590
Newburgh, NY-PA.....................................    1.0805    1.0545
Norfolk-Virginia Beach-Newport News, VA-NC..........    0.8378    0.8859
Oakland, CA.........................................    1.5199    1.3320
Oklahoma City, OK...................................    0.8705    0.9094
Omaha, NE-IA........................................    1.0722    1.0489
Orange County, CA...................................    1.1539    1.1030
Orlando, FL.........................................    0.9997    0.9998
Peoria-Pekin, IL....................................    0.8495    0.8943
Philadelphia, PA-NJ.................................    1.1077    1.0726
Phoenix-Mesa, AZ....................................    0.9546    0.9687
Pittsburgh, PA......................................    0.9537    0.9681
Pocatello, ID.......................................    0.8715    0.9101
Portland, ME........................................    0.9552    0.9691
Portland-Vancouver, OR-WA...........................    1.1091    1.0735
Provo-Orem, UT......................................    0.9786    0.9853
Raleigh-Durham-Chapel Hill, NC......................    0.9631    0.9746
Roanoke, VA.........................................    0.8224    0.8747
Rockford, IL........................................    0.8861    0.9205
Sacramento, CA......................................    1.2482    1.1640
Saginaw-Bay City-Midland, MI........................    0.9422    0.9600
St. Cloud, MN.......................................    0.9650    0.9759
St. Louis, MO-IL....................................    0.9186    0.9435
Salt Lake City-Ogden, UT............................    0.9884    0.9920
San Diego, CA.......................................    1.1943    1.1293
Santa Fe, NM........................................    0.9115    0.9385
Santa Rosa, CA......................................    1.3127    1.2048
Seattle-Bellevue-Everett, WA........................    1.1390    1.0932
Sharon, PA..........................................    0.8488    0.8938
Sherman-Denison, TX.................................    0.8782    0.9149
Sioux City, IA-NE...................................    0.8051    0.8620
South Bend, IN......................................    0.9791    0.9856
Springfield, MO.....................................    0.8003    0.8585
Syracuse, NY........................................    0.9527    0.9674
Tallahassee, FL.....................................    0.8545    0.8979
Tampa-St. Petersburg-Clearwater, FL.................    0.9260    0.9487
Texarkana, AR-Texarkana, TX.........................    0.8206    0.8734
Toledo, OH..........................................    0.9810    0.9870
Tulsa, OK...........................................    0.7852    0.8474
Tuscaloosa, AL......................................    0.7994    0.8579
Tyler, TX...........................................    0.8572    0.8999

[[Page 24802]]

 
Vallejo-Fairfield-Napa, CA..........................    1.2291    1.1517
Victoria, TX........................................    0.8062    0.8628
Waco, TX............................................    0.7561    0.8258
Washington, DC-MD-VA-WV.............................    1.1118    1.0753
Waterloo-Cedar Falls, IA............................    0.9039    0.9332
Wausau, WI..........................................    0.9545    0.9686
West Palm Beach-Boca Raton, FL......................    1.0167    1.0114
Wichita, KS.........................................    0.8857    0.9202
Rural Colorado......................................    0.8852    0.9199
Rural Florida.......................................    0.9074    0.9356
Rural Illinois......................................    0.8121    0.8672
Rural Louisiana.....................................    0.7519    0.8226
Rural Michigan......................................    0.8904    0.9236
Rural Minnesota.....................................    0.8753    0.9128
Rural Missouri......................................    0.7701    0.8362
Rural Montana.......................................    0.8528    0.8967
Rural Oregon........................................    1.0071    1.0049
Rural Pennsylvania (NY Hospital)....................    0.8633    0.9042
Rural Tennessee.....................................    0.7743    0.8393
Rural Texas (OK Hospital)...........................    0.7345    0.8095
Rural Virginia (KY Hospital)........................    0.8129    0.8677
Rural Washington....................................    1.0370    1.0252
Rural Wyoming.......................................    0.8891    0.9227
------------------------------------------------------------------------


             Table 4D.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
                                                                Average
                          Urban area                             hourly
                                                                  wage
------------------------------------------------------------------------
Abilene, TX..................................................    17.3384
Aguadilla, PR................................................     9.5600
Akron, OH....................................................    21.5487
Albany, GA...................................................    15.2742
Albany-Schenectady-Troy, NY..................................    18.0615
Albuquerque, NM..............................................    17.5627
Alexandria, LA...............................................    16.6620
Allentown-Bethlehem-Easton, PA...............................    21.7512
Altoona, PA..................................................    19.7557
Amarillo, TX.................................................    16.8825
Anchorage, AK................................................    27.2347
Ann Arbor, MI................................................    24.2486
Anniston, AL.................................................    17.9235
Appleton-Oshkosh-Neenah, WI..................................    18.7525
Arecibo, PR..................................................     9.9315
Asheville, NC................................................    18.8257
Athens, GA...................................................    20.0661
Atlanta, GA..................................................    21.2165
Atlantic-Cape May, NJ........................................    22.9089
Augusta-Aiken, GA-SC.........................................    19.1161
Austin-San Marcos, TX........................................    19.9429
Bakersfield, CA..............................................    20.3276
Baltimore, MD................................................    21.3358
Bangor, ME...................................................    20.3521
Barnstable-Yarmouth, MA......................................    27.2846
Baton Rouge, LA..............................................    18.4438
Beaumont-Port Arthur, TX.....................................    17.9374
Bellingham, WA...............................................    24.1321
Benton Harbor, MI............................................    17.9119
Bergen-Passaic, NJ...........................................    25.2711
Billings, MT.................................................    24.7467
Biloxi-Gulfport-Pascagoula, MS...............................    16.6634
Binghamton, NY...............................................    18.2442
Birmingham, AL...............................................    18.8910
Bismarck, ND.................................................    16.4329
Bloomington, IN..............................................    18.1990
Bloomington-Normal, IL.......................................    19.0474
Boise City, ID...............................................    19.1895
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.............    23.5756
Boulder-Longmont, CO.........................................    21.0610
Brazoria, TX.................................................    18.0160
Bremerton, WA................................................    23.3211
Brownsville-Harlingen-San Benito, TX.........................    19.3812
Bryan-College Station, TX....................................    17.7233
Buffalo-Niagara Falls, NY....................................    20.0987
Burlington, VT...............................................    21.9214
Caguas, PR...................................................     9.5514
Canton-Massillon, OH.........................................    18.5824
Casper, WY...................................................    19.4829
Cedar Rapids, IA.............................................    19.1010
Champaign-Urbana, IL.........................................    19.4065
Charleston-North Charleston, SC..............................    18.7959
Charleston, WV...............................................    19.2624
Charlotte-Gastonia-Rock Hill, NC-SC..........................    19.9662
Charlottesville, VA..........................................    22.3946
Chattanooga, TN-GA...........................................    20.7419
Cheyenne, WY.................................................    17.3158
Chicago, IL..................................................    22.7675
Chico-Paradise, CA...........................................    21.7666
Cincinnati, OH-KY-IN.........................................    19.8701
Clarksville-Hopkinsville, TN-KY..............................    17.1337
Cleveland-Lorain-Elyria, OH..................................    20.3885
Colorado Springs, CO.........................................    19.5228
Columbia, MO.................................................    18.8334
Columbia, SC.................................................    19.8182
Columbus, GA-AL..............................................    17.9587
Columbus, OH.................................................    20.5518
Corpus Christi, TX...........................................    19.5374
Cumberland, MD-WV............................................    18.6405
Dallas, TX...................................................    19.3512
Danville, VA.................................................    19.1906
Davenport-Moline-Rock Island, IA-IL..........................    18.4412
Dayton-Springfield, OH.......................................    19.9120
Daytona Beach, FL............................................    18.9525
Decatur, AL..................................................    20.9325
Decatur, IL..................................................    17.6402
Denver, CO...................................................    21.4632
Des Moines, IA...............................................    18.5542
Detroit, MI..................................................    21.9391
Dothan, AL...................................................    16.5159
Dover, DE....................................................    19.7645
Dubuque, IA..................................................    18.0451
Duluth-Superior, MN-WI.......................................    21.5499
Dutchess County, NY..........................................    22.2045
Eau Claire, WI...............................................    18.9735
El Paso, TX..................................................    18.8348
Elkhart-Goshen, IN...........................................    19.1690
Elmira, NY...................................................    18.0730
Enid, OK.....................................................    16.8452
Erie, PA.....................................................    19.0352
Eugene-Springfield, OR.......................................    22.0108
Evansville, Henderson, IN-KY.................................    17.5709
Fargo-Moorhead, ND-MN........................................    18.2572
Fayetteville, NC.............................................    17.9896
Fayetteville-Springdale-Rogers, AR...........................    16.4641
Flagstaff, AZ-UT.............................................    21.9164
Flint, MI....................................................    23.3401
Florence, AL.................................................    16.7894
Florence, SC.................................................    18.2544
Fort Collins-Loveland, CO....................................    21.8189
Fort Lauderdale, FL..........................................    21.5452
Fort Myers-Cape Coral, FL....................................    18.6973
Fort Pierce-Port St. Lucie, FL...............................    21.1349
Fort Smith, AR-OK............................................    16.6129
Fort Walton Beach, FL........................................    18.4550
Fort Wayne, IN...............................................    18.7461
Fort Worth-Arlington, TX.....................................    18.8776
Fresno, CA...................................................    21.7462
Gadsden, AL..................................................    18.4020
Gainesville, FL..............................................    21.3475
Galveston-Texas City, TX.....................................    20.0636
Gary, IN.....................................................    19.8645
Glens Falls, NY..............................................    18.2269
Goldsboro, NC................................................    17.6500
Grand Forks, ND-MN...........................................    19.2683
Grand Junction, CO...........................................    19.4809
Grand Rapids-Muskegon-Holland, MI............................    21.3218
Great Falls, MT..............................................    22.2802
Greeley, CO..................................................    19.8126
Green Bay, WI................................................    19.3280
Greensboro-Winston-Salem-High Point, NC......................    19.1271
Greenville, NC...............................................    20.0665
Greenville-Spartanburg-Anderson, SC..........................    19.2880
Hagerstown, MD...............................................    18.7266
Hamilton-Middletown, OH......................................    18.8172
Harrisburg-Lebanon-Carlisle, PA..............................    20.7504
Hartford, CT.................................................    23.2800
Hattiesburg, MS..............................................    16.1993
Hickory-Morganton-Lenoir, NC.................................    19.3688
Honolulu, HI.................................................    24.3141
Houma, LA....................................................    16.5978
Houston, TX..................................................    19.4711
Huntington-Ashland, WV-KY-OH.................................    20.6552
Huntsville, AL...............................................    18.6863
Indianapolis, IN.............................................    20.7074
Iowa City, IA................................................    20.3481
Jackson, MI..................................................    18.7230
Jackson, MS..................................................    17.7577
Jackson, TN..................................................    22.9654
Jacksonville, FL.............................................    18.8568
Jacksonville, NC.............................................    16.6300
Jamestown, NY................................................    16.6418
Janesville-Beloit, WI........................................    20.3455
Jersey City, NJ..............................................    24.5703
Johnson City-Kingsport-Bristol,
  TN-VA......................................................    18.6209
Johnstown, PA................................................    17.5658
Jonesboro, AR................................................    15.3149

[[Page 24803]]

 
Joplin, MO...................................................    16.2618
Kalamazoo-Battlecreek, MI....................................    21.1395
Kankakee, IL.................................................    17.5067
Kansas City, KS-MO...........................................    19.5015
Kenosha, WI..................................................    18.4010
Killeen-Temple, TX...........................................    21.0317
Knoxville, TN................................................    19.4838
Kokomo, IN...................................................    18.8885
La Crosse, WI-MN.............................................    18.9205
Lafayette, LA................................................    16.9163
Lafayette, IN................................................    18.6572
Lake Charles, LA.............................................    16.5668
Lakeland-Winter Haven, FL....................................    18.6713
Lancaster, PA................................................    18.7531
Lansing-East Lansing, MI.....................................    21.1588
Laredo, TX...................................................    17.6272
Las Cruces, NM...............................................    17.9392
Las Vegas, NV-AZ.............................................    23.4456
Lawrence, KS.................................................    17.4151
Lawton, OK...................................................    17.7694
Lewiston-Auburn, ME..........................................    18.8110
Lexington, KY................................................    18.1825
Lima, OH.....................................................    18.8613
Lincoln, NE..................................................    20.4820
Little Rock-North Little Rock, AR............................    18.2375
Longview-Marshall, TX........................................    18.5109
Los Angeles-Long Beach, CA...................................    24.8769
Louisville, KY-IN............................................    19.4923
Lubbock, TX..................................................    17.6926
Lynchburg, VA................................................    18.9720
Macon, GA....................................................    18.0637
Madison, WI..................................................    21.1696
Mansfield, OH................................................    17.9415
Mayaguez, PR.................................................    10.1946
McAllen-Edinburg-Mission, TX.................................    17.0929
Medford-Ashland, OR..........................................    22.2257
Melbourne-Titusville-Palm Bay, FL............................    19.6889
Memphis, TN-AR-MS............................................    16.9175
Merced, CA...................................................    21.7673
Miami, FL....................................................    21.6256
Middlesex-Somerset-Hunterdon, NJ.............................    23.6066
Milwaukee-Waukesha, WI.......................................    20.6321
Minneapolis-St. Paul, MN-WI..................................    22.2877
Missoula, MT.................................................    19.1769
Mobile, AL...................................................    17.4061
Modesto, CA..................................................    21.3504
Monmouth-Ocean, NJ...........................................    23.8424
Monroe, LA...................................................    17.4115
Montgomery, AL...............................................    14.6992
Muncie, IN...................................................    22.7904
Myrtle Beach, SC.............................................    18.1305
Naples, FL...................................................    21.4581
Nashville, TN................................................    19.1647
Nassau-Suffolk, NY...........................................    29.6122
New Haven-Bridgeport-Stamford-
  Waterbury-Danbury, CT......................................    26.1133
New London-Norwich, CT.......................................    22.3392
New Orleans, LA..............................................    19.0247
New York, NY.................................................    29.8414
Newark, NJ...................................................    25.1990
Newburgh, NY-PA..............................................    23.1041
Norfolk-Virginia Beach-Newport News, VA-NC...................    17.5474
Oakland, CA..................................................    31.7590
Ocala, FL....................................................    20.3639
Odessa-Midland, TX...........................................    16.8070
Oklahoma City, OK............................................    18.2516
Olympia, WA..................................................    26.7328
Omaha, NE-IA.................................................    22.4822
Orange County, CA............................................    24.1961
Orlando, FL..................................................    20.9377
Owensboro, KY................................................    16.1873
Panama City, FL..............................................    19.4291
Parkersburg-Marietta, WV-OH..................................    17.8217
Pensacola, FL................................................    17.8744
Peoria-Pekin, IL.............................................    17.6840
Philadelphia, PA-NJ..........................................    23.1971
Phoenix-Mesa, AZ.............................................    20.0149
Pine Bluff, AR...............................................    16.1227
Pittsburgh, PA...............................................    19.9963
Pittsfield, MA...............................................    22.5755
Pocatello, ID................................................    19.0128
Ponce, PR....................................................    10.5379
Portland, ME.................................................    19.9935
Portland-Vancouver, OR-WA....................................    23.2544
Providence-Warwick, RI.......................................    22.6214
Provo-Orem, UT...............................................    20.5053
Pueblo, CO...................................................    18.7505
Punta Gorda, FL..............................................    17.9293
Racine, WI...................................................    19.5201
Raleigh-Durham-Chapel Hill, NC...............................    20.1948
Rapid City, SD...............................................    17.7159
Reading, PA..................................................    19.9741
Redding, CA..................................................    23.8872
Reno, NV.....................................................    22.5678
Richland-Kennewick-Pasco, WA.................................    23.7721
Richmond-Petersburg, VA......................................    21.0784
Riverside-San Bernardino, CA.................................    22.6264
Roanoke, VA..................................................    17.2365
Rochester, MN................................................    23.1823
Rochester, NY................................................    19.8100
Rockford, IL.................................................    18.5789
Rocky Mount, NC..............................................    18.4997
Sacramento, CA...............................................    26.1722
Saginaw-Bay City-Midland, MI.................................    19.6590
St. Cloud, MN................................................    19.7777
St. Joseph, MO...............................................    18.5272
St. Louis, MO-IL.............................................    19.2606
Salem, OR....................................................    21.0721
Salinas, CA..................................................    30.8347
Salt Lake City-Ogden, UT.....................................    20.7240
San Angelo, TX...............................................    16.5012
San Antonio, TX..............................................    17.3414
San Diego, CA................................................    24.9816
San Francisco, CA............................................    29.7441
San Jose, CA.................................................    28.9924
San Juan-Bayamon, PR.........................................     9.9392
San Luis Obispo-Atascadero-
  Paso Robles, CA............................................    22.1746
Santa Barbara-Santa Maria-
  Lompoc, CA.................................................    22.9107
Santa Cruz-Watsonville, CA...................................    29.4979
Santa Fe, NM.................................................    19.0044
Santa Rosa, CA...............................................    27.5249
Sarasota-Bradenton, FL.......................................    20.8165
Savannah, GA.................................................    20.7408
Scranton-Wilkes Barre-Hazleton,
  PA.........................................................    17.2531
Seattle-Bellevue-Everett, WA.................................    23.8788
Sharon, PA...................................................    17.4261
Sheboygan, WI................................................    17.3719
Sherman-Denison, TX..........................................    19.3180
Shreveport-Bossier City, LA..................................    19.1689
Sioux City, IA-NE............................................    16.7521
Sioux Falls, SD..............................................    18.4052
South Bend, IN...............................................    20.7423
Spokane, WA..................................................    22.8349
Springfield, IL..............................................    18.3917
Springfield, MO..............................................    16.7813
Springfield, MA..............................................    22.2268
State College, PA............................................    19.3927
Steubenville-Weirton, OH-WV..................................    18.2449
Stockton-Lodi, CA............................................    22.2735
Sumter, SC...................................................    17.4486
Syracuse, NY.................................................    19.9107
Tacoma, WA...................................................    24.3185
Tallahassee, FL..............................................    18.5118
Tampa-St. Petersburg-Clearwater, FL..........................    19.2631
Terre Haute, IN..............................................    18.1855
Texarkana, AR-Texarkana, TX..................................    17.1104
Toledo, OH...................................................    21.0109
Topeka, KS...................................................    19.2788
Trenton, NJ..................................................    19.2422
Tucson, AZ...................................................    18.5156
Tulsa, OK....................................................    16.4631
Tuscaloosa, AL...............................................    16.7614
Tyler, TX....................................................    17.6966
Utica-Rome, NY...............................................    17.5752
Vallejo-Fairfield-Napa, CA...................................    28.2652
Ventura, CA..................................................    24.0627
Victoria, TX.................................................    16.7918
Vineland-Millville-Bridgeton, NJ.............................    22.2740
Visalia-Tulare-Porterville, CA...............................    21.8242
Waco, TX.....................................................    15.8347
Washington, DC-MD-VA-WV......................................    23.3111
Waterloo-Cedar Falls, IA.....................................    18.3856
Wausau, WI...................................................    20.0138
West Palm Beach-Boca Raton,
  FL.........................................................    21.2057
Wheeling, OH-WV..............................................    16.1880
Wichita, KS..................................................    19.1154
Wichita Falls, TX............................................    16.2079
Williamsport, PA.............................................    18.0547
Wilmington-Newark, DE-MD.....................................    23.8786
Wilmington, NC...............................................    20.8870
Yakima, WA...................................................    21.8824
Yolo, CA.....................................................    20.5840
York, PA.....................................................    19.5997
Youngstown-Warren, OH........................................    21.1722
Yuba City, CA................................................    22.5818
Yuma, AZ.....................................................    21.0182
------------------------------------------------------------------------


             Table 4E.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
                                                                Average
                        Nonurban area                            hourly
                                                                  wage
------------------------------------------------------------------------
Alabama......................................................    15.8142
Alaska.......................................................    25.5400
Arizona......................................................    18.0528
Arkansas.....................................................    15.2856
California...................................................    21.2880
Colorado.....................................................    18.5603

[[Page 24804]]

 
Connecticut..................................................    26.6122
Delaware.....................................................    19.4135
Florida......................................................    19.0250
Georgia......................................................    17.1694
Hawaii.......................................................    22.6698
Idaho........................................................    18.2722
Illinois.....................................................    17.0275
Indiana......................................................    17.7798
Iowa.........................................................    16.7742
Kansas.......................................................    15.7503
Kentucky.....................................................    17.0443
Louisiana....................................................    15.5331
Maine........................................................    18.2533
Maryland.....................................................    19.0722
Massachusetts................................................    20.7873
Michigan.....................................................    18.6349
Minnesota....................................................    18.3523
Mississippi..................................................    15.6269
Missouri.....................................................    16.1473
Montana......................................................    17.8810
Nebraska.....................................................    16.9308
Nevada.......................................................    20.1989
New Hampshire................................................    20.9206
New Jersey \1\...............................................  .........
New Mexico...................................................    18.0601
New York.....................................................    18.1015
North Carolina...............................................    17.5057
North Dakota.................................................    16.2498
Ohio.........................................................    18.2882
Oklahoma.....................................................    15.4011
Oregon.......................................................    21.1083
Pennsylvania.................................................    17.7969
Puerto Rico..................................................     9.1814
Rhode Island \1\.............................................  .........
South Carolina...............................................    17.9076
South Dakota.................................................    16.0683
Tennessee....................................................    16.2348
Texas........................................................    14.6891
Utah.........................................................    17.2326
Vermont......................................................    19.9290
Virginia.....................................................    16.6151
Washington...................................................    21.9605
West Virginia................................................    17.2069
Wisconsin....................................................    18.5387
Wyoming......................................................    18.6424
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


                Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
                                                                                Wage index--
                     Area                        Wage index          GAF        reclassified   GAF--reclassified
                                                                                  hospitals         hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR................................          0.9593          0.9719  ..............  .................
Arecibo, PR..................................          0.9965          0.9976  ..............  .................
Caguas, PR...................................          0.9584          0.9713          0.9584            0.9713
Mayaguez, PR.................................          1.0229          1.0156  ..............  .................
Ponce, PR....................................          1.0574          1.0390  ..............  .................
San Juan-Bayamon, PR.........................          0.9973          0.9982  ..............  .................
Rural Puerto Rico............................          0.9213          0.9454  ..............  .................
----------------------------------------------------------------------------------------------------------------


  Table 5.--List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean
                                                 Length of Stay
----------------------------------------------------------------------------------------------------------------
                                                                             Relative    Geometric    Arithmetic
      DRG          MDC        Type of DRG               DRG title            weights      mean LOS     mean LOS
----------------------------------------------------------------------------------------------------------------
1..............       01  SURG                 CRANIOTOMY AGE >17 EXCEPT        3.0845          6.5          9.3
                                                FOR TRAUMA.
2..............       01  SURG                 CRANIOTOMY FOR TRAUMA AGE        3.0989          7.4          9.9
                                                >17.
3..............       01  SURG                 *CRANIOTOMY AGE 0-17......       1.9619         12.7         12.7
4..............       01  SURG                 SPINAL PROCEDURES.........       2.3104          4.9          7.5
5..............       01  SURG                 EXTRACRANIAL VASCULAR            1.4462          2.5          3.4
                                                PROCEDURES.
6..............       01  SURG                 CARPAL TUNNEL RELEASE.....        .8119          2.2          3.1
7..............       01  SURG                 PERIPH & CRANIAL NERVE &         2.3667          6.6          9.8
                                                OTHER NERV SYST PROC W CC.
8..............       01  SURG                 PERIPH & CRANIAL NERVE &         1.3303          2.2          3.1
                                                OTHER NERV SYST PROC W/O
                                                CC.
9..............       01  MED                  SPINAL DISORDERS &               1.1785          4.6          6.2
                                                INJURIES.
10.............       01  MED                  NERVOUS SYSTEM NEOPLASMS W       1.2044          4.9          6.7
                                                CC.
11.............       01  MED                  NERVOUS SYSTEM NEOPLASMS W/       .8277          3.0          4.1
                                                O CC.
12.............       01  MED                  DEGENERATIVE NERVOUS              .8908          4.6          6.3
                                                SYSTEM DISORDERS.
13.............       01  MED                  MULTIPLE SCLEROSIS &              .7585          4.2          5.2
                                                CEREBELLAR ATAXIA.
14.............       01  MED                  SPECIFIC CEREBROVASCULAR         1.1924          4.7          6.1
                                                DISORDERS EXCEPT TIA.
15.............       01  MED                  TRANSIENT ISCHEMIC ATTACK         .7405          3.0          3.7
                                                & PRECEREBRAL OCCLUSIONS.
16.............       01  MED                  NONSPECIFIC                      1.0998          4.6          5.9
                                                CEREBROVASCULAR DISORDERS
                                                W CC.
17.............       01  MED                  NONSPECIFIC                       .6405          2.6          3.4
                                                CEREBROVASCULAR DISORDERS
                                                W/O CC.
18.............       01  MED                  CRANIAL & PERIPHERAL NERVE        .9365          4.2          5.5
                                                DISORDERS W CC.
19.............       01  MED                  CRANIAL & PERIPHERAL NERVE        .6504          3.0          3.8
                                                DISORDERS W/O CC.
20.............       01  MED                  NERVOUS SYSTEM INFECTION         2.6065          7.7         10.2
                                                EXCEPT VIRAL MENINGITIS.
21.............       01  MED                  VIRAL MENINGITIS..........       1.5010          5.0          6.8
22.............       01  MED                  HYPERTENSIVE                      .9637          3.8          4.9
                                                ENCEPHALOPATHY.
23.............       01  MED                  NONTRAUMATIC STUPOR & COMA        .7756          3.1          4.2
24.............       01  MED                  SEIZURE & HEADACHE AGE >17        .9782          3.7          5.1
                                                W CC.
25.............       01  MED                  SEIZURE & HEADACHE AGE >17        .5911          2.6          3.4
                                                W/O CC.
26.............       01  MED                  SEIZURE & HEADACHE AGE 0-         .6296          2.8          3.6
                                                17.

[[Page 24805]]

 
27.............       01  MED                  TRAUMATIC STUPOR & COMA,         1.3532          3.3          5.3
                                                COMA >1 HR.
28.............       01  MED                  TRAUMATIC STUPOR & COMA,         1.2680          4.5          6.2
                                                COMA <1 HR AGE >17 W CC.
29.............       01  MED                  TRAUMATIC STUPOR & COMA,          .6844          2.8          3.6
                                                COMA <1 HR AGE >17 W/O CC.
30.............       01  MED                  * TRAUMATIC STUPOR & COMA,        .3318          2.0          2.0
                                                COMA <1 HR AGE 0-17.
31.............       01  MED                  CONCUSSION AGE >17 W CC...        .8463          3.2          4.3
32.............       01  MED                  CONCUSSION AGE >17 W/O CC.        .5282          2.1          2.7
33.............       01  MED                  *CONCUSSION AGE 0-17......        .2085          1.6          1.6
34.............       01  MED                  OTHER DISORDERS OF NERVOUS       1.0267          4.0          5.3
                                                SYSTEM W CC.
35.............       01  MED                  OTHER DISORDERS OF NERVOUS        .5931          2.7          3.5
                                                SYSTEM W/O CC.
36.............       02  SURG                 RETINAL PROCEDURES........        .6804          1.2          1.4
37.............       02  SURG                 ORBITAL PROCEDURES........       1.0261          2.6          3.9
38.............       02  SURG                 PRIMARY IRIS PROCEDURES...        .4871          1.9          2.6
39.............       02  SURG                 LENS PROCEDURES WITH OR           .5682          1.4          1.9
                                                WITHOUT VITRECTOMY.
40.............       02  SURG                 EXTRAOCULAR PROCEDURES            .8131          2.2          3.3
                                                EXCEPT ORBIT AGE >17.
41.............       02  SURG                 *EXTRAOCULAR PROCEDURES           .3378          1.6          1.6
                                                EXCEPT ORBIT AGE 0-17.
42.............       02  SURG                 INTRAOCULAR PROCEDURES            .6222          1.6          2.1
                                                EXCEPT RETINA, IRIS &
                                                LENS.
43.............       02  MED                  HYPHEMA...................        .4416          2.5          4.1
44.............       02  MED                  ACUTE MAJOR EYE INFECTIONS        .6449          4.1          5.0
45.............       02  MED                  NEUROLOGICAL EYE DISORDERS        .6946          2.8          3.4
46.............       02  MED                  OTHER DISORDERS OF THE EYE        .7524          3.5          4.6
                                                AGE >17 W CC.
47.............       02  MED                  OTHER DISORDERS OF THE EYE        .4795          2.5          3.2
                                                AGE >17 W/O CC.
48.............       02  MED                  *OTHER DISORDERS OF THE           .2975          2.9          2.9
                                                EYE AGE 0-17.
49.............       03  SURG                 MAJOR HEAD & NECK                1.8471          3.7          5.0
                                                PROCEDURES.
50.............       03  SURG                 SIALOADENECTOMY...........        .8390          1.6          2.0
51.............       03  SURG                 SALIVARY GLAND PROCEDURES         .8486          1.9          2.9
                                                EXCEPT SIALOADEN-ECTOMY.
52.............       03  SURG                 CLEFT LIP & PALATE REPAIR.        .7954          1.6          2.0
53.............       03  SURG                 SINUS & MASTOID PROCEDURES       1.1767          2.3          3.6
                                                AGE >17.
54.............       03  SURG                 *SINUS & MASTOID                  .4823          3.2          3.2
                                                PROCEDURES AGE 0-17.
55.............       03  SURG                 MISCELLANEOUS EAR, NOSE,          .8648          1.9          2.8
                                                MOUTH & THROAT PROCEDURES.
56.............       03  SURG                 RHINOPLASTY...............        .8881          2.1          2.8
57.............       03  SURG                 T&A PROC, EXCEPT                 1.1571          3.0          4.8
                                                TONSILLECTOMY &/OR
                                                ADENOIDECTOMY ONLY, AGE
                                                >17.
58.............       03  SURG                 *T&A PROC, EXCEPT                 .2739          1.5          1.5
                                                TONSILLECTOMY &/OR
                                                ADENOIDECTOMY ONLY, AGE 0-
                                                17.
59.............       03  SURG                 TONSILLECTOMY &/OR                .6700          1.9          2.6
                                                ADENOIDECTOMY ONLY, AGE
                                                >17.
60.............       03  SURG                 *TONSILLECTOMY &/OR               .2086          1.5          1.5
                                                ADENOIDECTOMY ONLY, AGE 0-
                                                17.
61.............       03  SURG                 MYRINGOTOMY W TUBE               1.2529          2.9          4.8
                                                INSERTION AGE >17.
62.............       03  SURG                 *MYRINGOTOMY W TUBE               .2953          1.3          1.3
                                                INSERTION AGE 0-17.
63.............       03  SURG                 OTHER EAR, NOSE, MOUTH &         1.3078          3.0          4.5
                                                THROAT O.R. PROCEDURES.
64.............       03  MED                  EAR, NOSE, MOUTH & THROAT        1.2517          4.4          6.7
                                                MALIGNANCY.
65.............       03  MED                  DYSEQUILIBRIUM............        .5270          2.3          2.9
66.............       03  MED                  EPISTAXIS.................        .5551          2.6          3.2
67.............       03  MED                  EPIGLOTTITIS..............        .8059          2.9          3.7
68.............       03  MED                  OTITIS MEDIA & URI AGE >17        .6764          3.4          4.2
                                                W CC.
69.............       03  MED                  OTITIS MEDIA & URI AGE >17        .5210          2.7          3.3
                                                W/O CC.
70.............       03  MED                  OTITIS MEDIA & URI AGE 0-         .3989          2.3          2.7
                                                17.
71.............       03  MED                  LARYNGOTRACHEITIS.........        .6206          2.8          3.4
72.............       03  MED                  NASAL TRAUMA & DEFORMITY..        .6464          2.6          3.4
73.............       03  MED                  OTHER EAR, NOSE, MOUTH &          .7671          3.3          4.3
                                                THROAT DIAGNOSES AGE >17.
74.............       03  MED                  *OTHER EAR, NOSE, MOUTH &         .3356          2.1          2.1
                                                THROAT DIAGNOSES AGE 0-17.
75.............       04  SURG                 MAJOR CHEST PROCEDURES....       3.1078          7.8          9.9
76.............       04  SURG                 OTHER RESP SYSTEM O.R.           2.6947          8.3         11.1
                                                PROCEDURES W CC.
77.............       04  SURG                 OTHER RESP SYSTEM O.R.           1.2105          3.6          5.1
                                                PROCEDURES W/O CC.
78.............       04  MED                  PULMONARY EMBOLISM........       1.3898          6.1          7.1
79.............       04  MED                  RESPIRATORY INFECTIONS &         1.6472          6.6          8.4
                                                INFLAMMATIONS AGE >17 W
                                                CC.
80.............       04  MED                  RESPIRATORY INFECTIONS &          .9030          4.5          5.6
                                                INFLAMMATIONS AGE >17 W/O
                                                CC.
81.............       04  MED                  *RESPIRATORY INFECTIONS &        1.5196          6.1          6.1
                                                INFLAMMATIONS AGE 0-17.
82.............       04  MED                  RESPIRATORY NEOPLASMS.....       1.3674          5.2          7.0
83.............       04  MED                  MAJOR CHEST TRAUMA W CC...        .9723          4.3          5.5
84.............       04  MED                  MAJOR CHEST TRAUMA W/O CC.        .5250          2.6          3.2
85.............       04  MED                  PLEURAL EFFUSION W CC.....       1.2450          5.0          6.5

[[Page 24806]]

 
86.............       04  MED                  PLEURAL EFFUSION W/O CC...        .6706          2.8          3.8
87.............       04  MED                  PULMONARY EDEMA &                1.3741          4.8          6.3
                                                RESPIRATORY FAILURE.
88.............       04  MED                  CHRONIC OBSTRUCTIVE               .9431          4.3          5.3
                                                PULMONARY DISEASE.
89.............       04  MED                  SIMPLE PNEUMONIA &               1.0887          5.1          6.1
                                                PLEURISY AGE >17 W CC.
90.............       04  MED                  SIMPLE PNEUMONIA &                .6753          3.7          4.3
                                                PLEURISY AGE >17 W/O CC.
91.............       04  MED                  SIMPLE PNEUMONIA &                .6245          3.3          4.0
                                                PLEURISY AGE 0-17.
92.............       04  MED                  INTERSTITIAL LUNG DISEASE        1.1783          5.0          6.2
                                                W CC.
93.............       04  MED                  INTERSTITIAL LUNG DISEASE         .7624          3.5          4.3
                                                W/O CC.
94.............       04  MED                  PNEUMOTHORAX W CC.........       1.1942          4.8          6.4
95.............       04  MED                  PNEUMOTHORAX W/O CC.......        .5973          3.0          3.6
96.............       04  MED                  BRONCHITIS & ASTHMA AGE           .7963          3.9          4.8
                                                >17 W CC.
97.............       04  MED                  BRONCHITIS & ASTHMA AGE           .5974          3.1          3.7
                                                >17 W/O CC.
98.............       04  MED                  BRONCHITIS & ASTHMA AGE 0-        .6783          3.3          4.5
                                                17.
99.............       04  MED                  RESPIRATORY SIGNS &               .6842          2.4          3.1
                                                SYMPTOMS W CC.
100............       04  MED                  RESPIRATORY SIGNS &               .5289          1.8          2.2
                                                SYMPTOMS W/O CC.
101............       04  MED                  OTHER RESPIRATORY SYSTEM          .8502          3.3          4.4
                                                DIAGNOSES W CC.
102............       04  MED                  OTHER RESPIRATORY SYSTEM          .5426          2.1          2.7
                                                DIAGNOSES W/O CC.
103............       05  SURG                 HEART TRANSPLANT..........      19.0801         35.2         56.0
104............       05  SURG                 CARDIAC VALVE & OTHER            7.2220          9.3         11.9
                                                MAJOR CARDIOTHORACIC PROC
                                                W CARDIAC CATH.
105............       05  SURG                 CARDIAC VALVE & OTHER            5.6426          7.6          9.4
                                                MAJOR CARDIOTHORACIC PROC
                                                W/O CARDIAC CATH.
106............       05  SURG                 CORONARY BYPASS W PTCA....       7.3332          9.1         10.9
107............       05  SURG                 CORONARY BYPASS W CARDIAC        5.4624          9.3         10.5
                                                CATH.
108............       05  SURG                 OTHER CARDIOTHORACIC             5.7505          8.3         11.0
                                                PROCEDURES.
109............       05  SURG                 CORONARY BYPASS W/O PTCA         4.0337          6.9          7.8
                                                OR CARDIAC CATH.
110............       05  SURG                 MAJOR CARDIOVASCULAR             4.1531          7.3          9.6
                                                PROCEDURES W CC.
111............       05  SURG                 MAJOR CARDIOVASCULAR             2.2236          4.9          5.7
                                                PROCEDURES W/O CC.
112............       05  SURG                 PERCUTANEOUS                     1.9200          2.7          3.8
                                                CARDIOVASCULAR PROCEDURES.
113............       05  SURG                 AMPUTATION FOR CIRC SYSTEM       2.7188          9.5         12.5
                                                DISORDERS EXCEPT UPPER
                                                LIMB & TOE.
114............       05  SURG                 UPPER LIMB & TOE                 1.5531          6.0          8.2
                                                AMPUTATION FOR CIRC
                                                SYSTEM DISORDERS.
115............       05  SURG                 PRM CARD PACEM IMPL W AMI,       3.4736          6.2          8.4
                                                HRT FAIL OR SHK, OR AICD
                                                LEAD OR GNRTR PR.
116............       05  SURG                 OTH PERM CARD PACEMAK IMPL       2.4635          2.8          3.9
                                                OR PTCA W CORONARY ARTERY
                                                STENT IMPLNT.
117............       05  SURG                 CARDIAC PACEMAKER REVISION       1.2942          2.7          4.1
                                                EXCEPT DEVICE REPLACEMENT.
118............       05  SURG                 CARDIAC PACEMAKER DEVICE         1.5475          2.0          2.9
                                                REPLACEMENT.
119............       05  SURG                 VEIN LIGATION & STRIPPING.       1.2288          3.0          4.9
120............       05  SURG                 OTHER CIRCULATORY SYSTEM         2.0093          5.0          8.2
                                                O.R. PROCEDURES.
121............       05  MED                  CIRCULATORY DISORDERS W          1.6318          5.6          6.8
                                                AMI & MAJOR COMP,
                                                DISCHARGED ALIVE.
122............       05  MED                  CIRCULATORY DISORDERS W          1.1091          3.4          4.2
                                                AMI W/O MAJOR COMP,
                                                DISCHARGED ALIVE.
123............       05  MED                  CIRCULATORY DISORDERS W          1.5135          2.7          4.4
                                                AMI, EXPIRED.
124............       05  MED                  CIRCULATORY DISORDERS            1.4018          3.4          4.5
                                                EXCEPT AMI, W CARD CATH &
                                                COMPLEX DIAG.
125............       05  MED                  CIRCULATORY DISORDERS            1.0436          2.2          2.9
                                                EXCEPT AMI, W CARD CATH W/
                                                O COMPLEX DIAG.
126............       05  MED                  ACUTE & SUBACUTE                 2.5151          9.3         12.1
                                                ENDOCARDITIS.
127............       05  MED                  HEART FAILURE & SHOCK.....       1.0156          4.2          5.4
128............       05  MED                  DEEP VEIN THROMBOPHLEBITIS        .7656          5.1          5.9
129............       05  MED                  CARDIAC ARREST,                  1.0799          1.8          2.8
                                                UNEXPLAINED.
130............       05  MED                  PERIPHERAL VASCULAR               .9475          4.7          5.9
                                                DISORDERS W CC.
131............       05  MED                  PERIPHERAL VASCULAR               .6057          3.7          4.5
                                                DISORDERS W/O CC.
132............       05  MED                  ATHEROSCLEROSIS W CC......        .6723          2.5          3.1
133............       05  MED                  ATHEROSCLEROSIS W/O CC....        .5656          1.9          2.4
134............       05  MED                  HYPERTENSION..............        .5857          2.6          3.3
135............       05  MED                  CARDIAC CONGENITAL &              .8643          3.3          4.4
                                                VALVULAR DISORDERS AGE
                                                >17 W CC.
136............       05  MED                  CARDIAC CONGENITAL &              .6011          2.3          2.9
                                                VALVULAR DISORDERS AGE
                                                >17 W/O CC.
137............       05  MED                  *CARDIAC CONGENITAL &             .8188          3.3          3.3
                                                VALVULAR DISORDERS AGE 0-
                                                17.
138............       05  MED                  CARDIAC ARRHYTHMIA &              .8164          3.1          4.0
                                                CONDUCTION DISORDERS W CC.

[[Page 24807]]

 
139............       05  MED                  CARDIAC ARRHYTHMIA &              .5087          2.1          2.5
                                                CONDUCTION DISORDERS W/O
                                                CC.
140............       05  MED                  ANGINA PECTORIS...........        .5840          2.3          2.8
141............       05  MED                  SYNCOPE & COLLAPSE W CC...        .7094          2.9          3.7
142............       05  MED                  SYNCOPE & COLLAPSE W/O CC.        .5426          2.2          2.7
143............       05  MED                  CHEST PAIN................        .5348          1.8          2.2
144............       05  MED                  OTHER CIRCULATORY SYSTEM         1.1513          3.8          5.3
                                                DIAGNOSES W CC.
145............       05  MED                  OTHER CIRCULATORY SYSTEM          .6502          2.2          2.8
                                                DIAGNOSES W/O CC.
146............       06  SURG                 RECTAL RESECTION W CC.....       2.7908          9.1         10.3
147............       06  SURG                 RECTAL RESECTION W/O CC...       1.6377          6.1          6.7
148............       06  SURG                 MAJOR SMALL & LARGE BOWEL        3.4324         10.1         12.1
                                                PROCEDURES W CC.
149............       06  SURG                 MAJOR SMALL & LARGE BOWEL        1.5743          6.2          6.7
                                                PROCEDURES W/O CC.
150............       06  SURG                 PERITONEAL ADHESIOLYSIS W        2.8115          9.1         11.0
                                                CC.
151............       06  SURG                 PERITONEAL ADHESIOLYSIS W/       1.3464          4.9          6.0
                                                O CC.
152............       06  SURG                 MINOR SMALL & LARGE BOWEL        1.9571          6.9          8.3
                                                PROCEDURES W CC.
153............       06  SURG                 MINOR SMALL & LARGE BOWEL        1.2162          5.0          5.6
                                                PROCEDURES W/O CC.
154............       06  SURG                 STOMACH, ESOPHAGEAL &            4.1380         10.1         13.2
                                                DUODENAL PROCEDURES AGE
                                                >17 W CC.
155............       06  SURG                 STOMACH, ESOPHAGEAL &            1.3793          3.5          4.5
                                                DUODENAL PROCEDURES AGE
                                                >17 W/O CC.
156............       06  SURG                 *STOMACH, ESOPHAGEAL &            .8432          6.0          6.0
                                                DUODENAL PROCEDURES AGE 0-
                                                17.
157............       06  SURG                 ANAL & STOMAL PROCEDURES W       1.2385          4.0          5.6
                                                CC.
158............       06  SURG                 ANAL & STOMAL PROCEDURES W/       .6580          2.1          2.6
                                                O CC.
159............       06  SURG                 HERNIA PROCEDURES EXCEPT         1.3127          3.7          5.0
                                                INGUINAL & FEMORAL AGE
                                                >17 W CC.
160............       06  SURG                 HERNIA PROCEDURES EXCEPT          .7817          2.2          2.7
                                                INGUINAL & FEMORAL AGE
                                                >17 W/O CC.
161............       06  SURG                 INGUINAL & FEMORAL HERNIA        1.1002          2.9          4.2
                                                PROCEDURES AGE >17 W CC.
162............       06  SURG                 INGUINAL & FEMORAL HERNIA         .6292          1.6          2.0
                                                PROCEDURES AGE >17 W/O CC.
163............       06  SURG                 *HERNIA PROCEDURES AGE 0-         .8720          2.1          2.1
                                                17.
164............       06  SURG                 APPENDECTOMY W COMPLICATED       2.3538          7.3          8.5
                                                PRINCIPAL DIAG W CC.
165............       06  SURG                 APPENDECTOMY W COMPLICATED       1.2706          4.4          4.9
                                                PRINCIPAL DIAG W/O CC.
166............       06  SURG                 APPENDECTOMY W/O                 1.4861          4.1          5.2
                                                COMPLICATED PRINCIPAL
                                                DIAG W CC.
167............       06  SURG                 APPENDECTOMY W/O                  .9038          2.4          2.8
                                                COMPLICATED PRINCIPAL
                                                DIAG W/O CC.
168............       03  SURG                 MOUTH PROCEDURES W CC.....       1.2131          3.3          4.7
169............       03  SURG                 MOUTH PROCEDURES W/O CC...        .7494          1.9          2.5
170............       06  SURG                 OTHER DIGESTIVE SYSTEM           2.8361          7.8         11.2
                                                O.R. PROCEDURES W CC.
171............       06  SURG                 OTHER DIGESTIVE SYSTEM           1.2561          3.6          4.8
                                                O.R. PROCEDURES W/O CC.
172............       06  MED                  DIGESTIVE MALIGNANCY W CC.       1.3135          5.1          6.9
173............       06  MED                  DIGESTIVE MALIGNANCY W/O          .7110          2.7          3.8
                                                CC.
174............       06  MED                  G.I. HEMORRHAGE W CC......        .9997          3.9          4.9
175............       06  MED                  G.I. HEMORRHAGE W/O CC....        .5466          2.5          2.9
176............       06  MED                  COMPLICATED PEPTIC ULCER..       1.0992          4.1          5.3
177............       06  MED                  UNCOMPLICATED PEPTIC ULCER        .8823          3.7          4.5
                                                W CC.
178............       06  MED                  UNCOMPLICATED PEPTIC ULCER        .6525          2.7          3.2
                                                W/O CC.
179............       06  MED                  INFLAMMATORY BOWEL DISEASE       1.0909          4.8          6.2
180............       06  MED                  G.I. OBSTRUCTION W CC.....        .9229          4.2          5.4
181............       06  MED                  G.I. OBSTRUCTION W/O CC...        .5285          2.8          3.4
182............       06  MED                  ESOPHAGITIS, GASTROENT &          .7834          3.4          4.3
                                                MISC DIGEST DISORDERS AGE
                                                >17 W CC.
183............       06  MED                  ESOPHAGITIS, GASTROENT &          .5726          2.4          3.0
                                                MISC DIGEST DISORDERS AGE
                                                >17 W/O CC.
184............       06  MED                  ESOPHAGITIS, GASTROENT &          .5266          2.3          3.0
                                                MISC DIGEST DISORDERS AGE
                                                0-17.
185............       03  MED                  DENTAL & ORAL DIS EXCEPT          .8560          3.3          4.5
                                                EXTRACTIONS &
                                                RESTORATIONS, AGE >17.
186............       03  MED                  *DENTAL & ORAL DIS EXCEPT         .3214          2.9          2.9
                                                EXTRACTIONS &
                                                RESTORATIONS, AGE 0-17.
187............       03  MED                  DENTAL EXTRACTIONS &              .7772          2.9          3.9
                                                RESTORATIONS.
188............       06  MED                  OTHER DIGESTIVE SYSTEM           1.0941          4.1          5.6
                                                DIAGNOSES AGE >17 W CC.
189............       06  MED                  OTHER DIGESTIVE SYSTEM            .5841          2.4          3.2
                                                DIAGNOSES AGE >17 W/O CC.
190............       06  MED                  OTHER DIGESTIVE SYSTEM            .9681          3.8          5.6
                                                DIAGNOSES AGE 0-17.
191............       07  SURG                 PANCREAS, LIVER & SHUNT          4.3647         10.6         14.2
                                                PROCEDURES W CC.
192............       07  SURG                 PANCREAS, LIVER & SHUNT          1.8479          5.7          7.0
                                                PROCEDURES W/O CC.

[[Page 24808]]

 
193............       07  SURG                 BILIARY TRACT PROC EXCEPT        3.4150         10.3         12.7
                                                ONLY CHOLECYST W OR W/O
                                                C.D.E. W CC.
194............       07  SURG                 BILIARY TRACT PROC EXCEPT        1.6394          5.4          6.6
                                                ONLY CHOLECYST W OR W/O
                                                C.D.E. W/O CC.
195............       07  SURG                 CHOLECYSTECTOMY W C.D.E. W       2.9468          8.4         10.0
                                                CC.
196............       07  SURG                 CHOLECYSTECTOMY W C.D.E. W/      1.6603          4.9          5.7
                                                O CC.
197............       07  SURG                 CHOLECYSTECTOMY EXCEPT BY        2.4209          7.1          8.6
                                                LAPAROSCOPE W/O C.D.E. W
                                                CC.
198............       07  SURG                 CHOLECYSTECTOMY EXCEPT BY        1.2360          3.9          4.5
                                                LAPAROSCOPE W/O C.D.E. W/
                                                O CC.
199............       07  SURG                 HEPATOBILIARY DIAGNOSTIC         2.3278          7.2          9.7
                                                PROCEDURE FOR MALIGNANCY.
200............       07  SURG                 HEPATOBILIARY DIAGNOSTIC         3.0720          7.2         11.1
                                                PROCEDURE FOR NON-
                                                MALIGNANCY.
201............       07  SURG                 OTHER HEPATOBILIARY OR           3.5771         10.3         14.2
                                                PANCREAS O.R. PROCEDURES.
202............       07  MED                  CIRRHOSIS & ALCOHOLIC            1.3202          5.0          6.6
                                                HEPATITIS.
203............       07  MED                  MALIGNANCY OF                    1.3042          5.0          6.7
                                                HEPATOBILIARY SYSTEM OR
                                                PANCREAS.
204............       07  MED                  DISORDERS OF PANCREAS            1.2186          4.6          6.0
                                                EXCEPT MALIGNANCY.
205............       07  MED                  DISORDERS OF LIVER EXCEPT        1.1831          4.7          6.4
                                                MALIG, CIRR, ALC HEPA W
                                                CC.
206............       07  MED                  DISORDERS OF LIVER EXCEPT         .7257          3.1          4.1
                                                MALIG, CIRR, ALC HEPA W/O
                                                CC.
207............       07  MED                  DISORDERS OF THE BILIARY         1.1049          4.0          5.2
                                                TRACT W CC.
208............       07  MED                  DISORDERS OF THE BILIARY          .6473          2.3          2.9
                                                TRACT W/O CC.
209............       08  SURG                 MAJOR JOINT & LIMB               2.1217          4.6          5.2
                                                REATTACHMENT PROCEDURES
                                                OF LOWER EXTREMITY.
210............       08  SURG                 HIP & FEMUR PROCEDURES           1.8053          5.9          6.8
                                                EXCEPT MAJOR JOINT AGE
                                                >17 W CC.
211............       08  SURG                 HIP & FEMUR PROCEDURES           1.2625          4.5          4.9
                                                EXCEPT MAJOR JOINT AGE
                                                >17 W/O CC.
212............       08  SURG                 *HIP & FEMUR PROCEDURES           .8468         11.1         11.1
                                                EXCEPT MAJOR JOINT AGE 0-
                                                17.
213............       08  SURG                 AMPUTATION FOR                   1.7128          6.1          8.3
                                                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                      2.1374          6.9          9.5
                                                MUSCULOSKELETAL SYSTEM &
                                                CONNECTIVE TISSUE.
217............       08  SURG                 WND DEBRID & SKN GRFT            2.7842          8.6         12.6
                                                EXCEPT HAND, FOR
                                                MUSCSKELET & CONN TISS
                                                DIS.
218............       08  SURG                 LOWER EXTREM & HUMER PROC        1.4902          4.2          5.3
                                                EXCEPT HIP, FOOT, FEMUR
                                                AGE >17 W CC.
219............       08  SURG                 LOWER EXTREM & HUMER PROC        1.0127          2.7          3.2
                                                EXCEPT HIP, FOOT, FEMUR
                                                AGE >17 W/O CC.
220............       08  SURG                 *LOWER EXTREM & HUMER PROC        .5841          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,        .9394          2.0          2.6
                                                OR OTHER UPPER EXTREMITY
                                                PROC W CC.
224............       08  SURG                 SHOULDER, ELBOW OR FOREARM        .8046          1.7          2.0
                                                PROC, EXC MAJOR JOINT
                                                PROC, W/O CC.
225............       08  SURG                 FOOT PROCEDURES...........       1.0528          3.2          4.5
226............       08  SURG                 SOFT TISSUE PROCEDURES W         1.4373          4.1          6.0
                                                CC.
227............       08  SURG                 SOFT TISSUE PROCEDURES W/O        .8175          2.1          2.8
                                                CC.
228............       08  SURG                 MAJOR THUMB OR JOINT PROC,       1.0502          2.4          3.6
                                                OR OTH HAND OR WRIST PROC
                                                W CC.
229............       08  SURG                 HAND OR WRIST PROC, EXCEPT        .7328          1.9          2.4
                                                MAJOR JOINT PROC, W/O CC.
230............       08  SURG                 LOCAL EXCISION & REMOVAL         1.1609          3.2          4.7
                                                OF INT FIX DEVICES OF HIP
                                                & FEMUR.
231............       08  SURG                 LOCAL EXCISION & REMOVAL         1.3614          3.1          4.6
                                                OF INT FIX DEVICES EXCEPT
                                                HIP & FEMUR.
232............       08  SURG                 ARTHROSCOPY...............       1.1675          2.4          4.1
233............       08  SURG                 OTHER MUSCULOSKELET SYS &        2.0314          5.3          7.5
                                                CONN TISS O.R. PROC W CC.
234............       08  SURG                 OTHER MUSCULOSKELET SYS &        1.2439          2.7          3.4
                                                CONN TISS O.R. PROC W/O
                                                CC.

[[Page 24809]]

 
235............       08  MED                  FRACTURES OF FEMUR........        .7475          3.8          5.1
236............       08  MED                  FRACTURES OF HIP & PELVIS.        .7167          3.9          5.0
237............       08  MED                  SPRAINS, STRAINS, &               .5445          2.9          3.6
                                                DISLOCATIONS OF HIP,
                                                PELVIS & THIGH.
238............       08  MED                  OSTEOMYELITIS.............       1.2827          6.4          8.4
239............       08  MED                  PATHOLOGICAL FRACTURES &          .9657          4.9          6.3
                                                MUSCULOSKELETAL & CONN
                                                TISS MALIGNANCY.
240............       08  MED                  CONNECTIVE TISSUE                1.2316          5.0          6.7
                                                DISORDERS W CC.
241............       08  MED                  CONNECTIVE TISSUE                 .6066          3.2          4.0
                                                DISORDERS W/O CC.
242............       08  MED                  SEPTIC ARTHRITIS..........       1.0152          5.1          6.6
243............       08  MED                  MEDICAL BACK PROBLEMS.....        .7170          3.8          4.7
244............       08  MED                  BONE DISEASES & SPECIFIC          .7014          3.8          4.8
                                                ARTHROPATHIES W CC.
245............       08  MED                  BONE DISEASES & SPECIFIC          .4801          2.8          3.6
                                                ARTHROPATHIES W/O CC.
246............       08  MED                  NON-SPECIFIC ARTHROPATHIES        .5573          3.0          3.7
247............       08  MED                  SIGNS & SYMPTOMS OF               .5564          2.6          3.4
                                                MUSCULOSKELETAL SYSTEM &
                                                CONN TISSUE.
248............       08  MED                  TENDONITIS, MYOSITIS &            .7566          3.6          4.6
                                                BURSITIS.
249............       08  MED                  AFTERCARE, MUSCULOSKELETAL        .6508          2.5          3.5
                                                SYSTEM & CONNECTIVE
                                                TISSUE.
250............       08  MED                  FX, SPRN, STRN & DISL OF          .6705          3.2          4.1
                                                FOREARM, HAND, FOOT AGE
                                                >17 W CC.
251............       08  MED                  FX, SPRN, STRN & DISL OF          .4615          2.3          2.9
                                                FOREARM, HAND, FOOT AGE
                                                >17 W/O CC.
252............       08  MED                  *FX, SPRN, STRN & DISL OF         .2537          1.8          1.8
                                                FOREARM, HAND, FOOT AGE 0-
                                                17.
253............       08  MED                  FX, SPRN, STRN & DISL OF          .7273          3.7          4.8
                                                UPARM, LOWLEG EX FOOT AGE
                                                >17 W CC.
254............       08  MED                  FX, SPRN, STRN & DISL OF          .4344          2.6          3.2
                                                UPARM, LOWLEG EX FOOT AGE
                                                >17 W/O CC.
255............       08  MED                  *FX, SPRN, STRN & DISL OF         .2954          2.9          2.9
                                                UPARM, LOWLEG EX FOOT AGE
                                                0-17.
256............       08  MED                  OTHER MUSCULOSKELETAL             .7645          3.8          5.1
                                                SYSTEM & CONNECTIVE
                                                TISSUE DIAGNOSES.
257............       09  SURG                 TOTAL MASTECTOMY FOR              .9153          2.3          2.9
                                                MALIGNANCY W CC.
258............       09  SURG                 TOTAL MASTECTOMY FOR              .7242          1.8          2.1
                                                MALIGNANCY W/O CC.
259............       09  SURG                 SUBTOTAL MASTECTOMY FOR           .8671          1.9          2.8
                                                MALIGNANCY W CC.
260............       09  SURG                 SUBTOTAL MASTECTOMY FOR           .6428          1.3          1.5
                                                MALIGNANCY W/O CC.
261............       09  SURG                 BREAST PROC FOR NON-              .9205          1.7          2.2
                                                MALIGNANCY EXCEPT BIOPSY
                                                & LOCAL EXCISION.
262............       09  SURG                 BREAST BIOPSY & LOCAL             .8409          2.7          3.9
                                                EXCISION FOR NON-
                                                MALIGNANCY.
263............       09  SURG                 SKIN GRAFT &/OR DEBRID FOR       2.0527          8.6         11.8
                                                SKN ULCER OR CELLULITIS W
                                                CC.
264............       09  SURG                 SKIN GRAFT &/OR DEBRID FOR       1.1213          5.3          7.1
                                                SKN ULCER OR CELLULITIS W/
                                                O CC.
265............       09  SURG                 SKIN GRAFT &/OR DEBRID           1.5630          4.4          7.0
                                                EXCEPT FOR SKIN ULCER OR
                                                CELLULITIS W CC.
266............       09  SURG                 SKIN GRAFT &/OR DEBRID            .8479          2.4          3.3
                                                EXCEPT FOR SKIN ULCER OR
                                                CELLULITIS W/O CC.
267............       09  SURG                 PERIANAL & PILONIDAL              .9756          2.9          4.1
                                                PROCEDURES.
268............       09  SURG                 SKIN, SUBCUTANEOUS TISSUE        1.1919          2.4          3.8
                                                & BREAST PLASTIC
                                                PROCEDURES.
269............       09  SURG                 OTHER SKIN, SUBCUT TISS &        1.6213          5.6          7.9
                                                BREAST PROC W CC.
270............       09  SURG                 OTHER SKIN, SUBCUT TISS &         .7435          2.2          3.1
                                                BREAST PROC W/O CC.
271............       09  MED                  SKIN ULCERS...............        .9921          5.6          7.1
272............       09  MED                  MAJOR SKIN DISORDERS W CC.        .9989          4.8          6.3
273............       09  MED                  MAJOR SKIN DISORDERS W/O          .6270          3.3          4.4
                                                CC.
274............       09  MED                  MALIGNANT BREAST DISORDERS       1.1271          4.7          6.5
                                                W CC.
275............       09  MED                  MALIGNANT BREAST DISORDERS        .6269          2.5          3.8
                                                W/O CC.
276............       09  MED                  NON-MALIGANT BREAST               .6538          3.5          4.4
                                                DISORDERS.
277............       09  MED                  CELLULITIS AGE >17 W CC...        .8323          4.7          5.8
278............       09  MED                  CELLULITIS AGE >17 W/O CC.        .5628          3.7          4.4
279............       09  MED                  CELLULITIS AGE 0-17.......        .6722          4.1          5.1
280............       09  MED                  TRAUMA TO THE SKIN, SUBCUT        .6740          3.3          4.2
                                                TISS & BREAST AGE >17 W
                                                CC.
281............       09  MED                  TRAUMA TO THE SKIN, SUBCUT        .4577          2.4          3.1
                                                TISS & BREAST AGE >17 W/O
                                                CC.

[[Page 24810]]

 
282............       09  MED                  *TRAUMA TO THE SKIN,              .2569          2.2          2.2
                                                SUBCUT TISS & BREAST AGE
                                                0-17.
283............       09  MED                  MINOR SKIN DISORDERS W CC.        .7141          3.6          4.7
284............       09  MED                  MINOR SKIN DISORDERS W/O          .4375          2.5          3.2
                                                CC.
285............       10  SURG                 AMPUTAT OF LOWER LIMB FOR        2.0096          7.7         10.6
                                                ENDOCRINE, NUTRIT, &
                                                METABOL DISORDERS.
286............       10  SURG                 ADRENAL & PITUITARY              2.2196          5.2          6.6
                                                PROCEDURES.
287............       10  SURG                 SKIN GRAFTS & WOUND DEBRID       1.8074          7.4         10.4
                                                FOR ENDOC, NUTRIT & METAB
                                                DISORDERS.
288............       10  SURG                 O.R. PROCEDURES FOR              2.0819          4.6          5.7
                                                OBESITY.
289............       10  SURG                 PARATHYROID PROCEDURES....        .9714          2.0          3.0
290............       10  SURG                 THYROID PROCEDURES........        .9187          1.9          2.4
291............       10  SURG                 THYROGLOSSAL PROCEDURES...        .6730          1.6          2.0
292............       10  SURG                 OTHER ENDOCRINE, NUTRIT &        2.4603          7.1         10.4
                                                METAB O.R. PROC W CC.
293............       10  SURG                 OTHER ENDOCRINE, NUTRIT &        1.1770          3.5          4.9
                                                METAB O.R. PROC W/O CC.
294............       10  MED                  DIABETES AGE >35..........        .7528          3.7          4.8
295............       10  MED                  DIABETES AGE 0-35.........        .7460          3.0          3.9
296............       10  MED                  NUTRITIONAL & MISC                .8567          4.0          5.3
                                                METABOLIC DISORDERS AGE
                                                >17 W CC.
297............       10  MED                  NUTRITIONAL & MISC                .5213          2.8          3.5
                                                METABOLIC DISORDERS AGE
                                                >17 W/O CC.
298............       10  MED                  NUTRITIONAL & MISC                .4976          2.4          3.5
                                                METABOLIC DISORDERS AGE 0-
                                                17.
299............       10  MED                  INBORN ERRORS OF                  .9448          3.8          5.4
                                                METABOLISM.
300............       10  MED                  ENDOCRINE DISORDERS W CC..       1.0797          4.8          6.2
301............       10  MED                  ENDOCRINE DISORDERS W/O CC        .5883          2.8          3.6
302............       11  SURG                 KIDNEY TRANSPLANT.........       3.5315          8.2          9.7
303............       11  SURG                 KIDNEY, URETER & MAJOR           2.5381          7.2          8.7
                                                BLADDER PROCEDURES FOR
                                                NEOPLASM.
304............       11  SURG                 KIDNEY, URETER & MAJOR           2.3395          6.5          8.9
                                                BLADDER PROC FOR NON-
                                                NEOPL W CC.
305............       11  SURG                 KIDNEY, URETER & MAJOR           1.1790          3.2          3.9
                                                BLADDER PROC FOR NON-
                                                NEOPL W/O CC.
306............       11  SURG                 PROSTATECTOMY W CC........       1.2476          3.7          5.4
307............       11  SURG                 PROSTATECTOMY W/O CC......        .6587          2.0          2.4
308............       11  SURG                 MINOR BLADDER PROCEDURES W       1.5880          4.1          6.1
                                                CC.
309............       11  SURG                 MINOR BLADDER PROCEDURES W/       .9430          2.0          2.5
                                                O CC.
310............       11  SURG                 TRANSURETHRAL PROCEDURES W       1.0881          3.0          4.3
                                                CC.
311............       11  SURG                 TRANSURETHRAL PROCEDURES W/       .6130          1.6          1.9
                                                O CC.
312............       11  SURG                 URETHRAL PROCEDURES, AGE         1.0283          3.1          4.6
                                                >17 W CC.
313............       11  SURG                 URETHRAL PROCEDURES, AGE          .6653          1.8          2.4
                                                >17 W/O CC.
314............       11  SURG                 *URETHRAL PROCEDURES, AGE         .4950          2.3          2.3
                                                0-17.
315............       11  SURG                 OTHER KIDNEY & URINARY           2.0624          4.5          7.8
                                                TRACT O.R. PROCEDURES.
316............       11  MED                  RENAL FAILURE.............       1.3389          4.9          6.7
317............       11  MED                  ADMIT FOR RENAL DIALYSIS..        .6906          2.1          3.2
318............       11  MED                  KIDNEY & URINARY TRACT           1.1406          4.4          6.0
                                                NEOPLASMS W CC.
319............       11  MED                  KIDNEY & URINARY TRACT            .6201          2.1          2.9
                                                NEOPLASMS W/O CC.
320............       11  MED                  KIDNEY & URINARY TRACT            .8664          4.4          5.4
                                                INFECTIONS AGE >17 W CC.
321............       11  MED                  KIDNEY & URINARY TRACT            .5797          3.3          3.9
                                                INFECTIONS AGE >17 W/O CC.
322............       11  MED                  KIDNEY & URINARY TRACT            .5653          3.0          3.8
                                                INFECTIONS AGE 0-17.
323............       11  MED                  URINARY STONES W CC, &/OR         .7851          2.4          3.2
                                                ESW LITHOTRIPSY.
324............       11  MED                  URINARY STONES W/O CC.....        .4491          1.6          1.9
325............       11  MED                  KIDNEY & URINARY TRACT            .6292          3.0          3.9
                                                SIGNS & SYMPTOMS AGE >17
                                                W CC.
326............       11  MED                  KIDNEY & URINARY TRACT            .4193          2.2          2.7
                                                SIGNS & SYMPTOMS AGE >17
                                                W/O CC.
327............       11  MED                  *KIDNEY & URINARY TRACT           .3541          3.1          3.1
                                                SIGNS & SYMPTOMS AGE 0-17.
328............       11  MED                  URETHRAL STRICTURE AGE >17        .7043          2.7          3.7
                                                W CC.
329............       11  MED                  URETHRAL STRICTURE AGE >17        .5215          1.7          2.5
                                                W/O CC.
330............       11  MED                  *URETHRAL STRICTURE AGE 0-        .3189          1.6          1.6
                                                17.
331............       11  MED                  OTHER KIDNEY & URINARY           1.0149          4.1          5.5
                                                TRACT DIAGNOSES AGE >17 W
                                                CC.
332............       11  MED                  OTHER KIDNEY & URINARY            .6079          2.6          3.4
                                                TRACT DIAGNOSES AGE >17 W/
                                                O CC.
333............       11  MED                  OTHER KIDNEY & URINARY            .7660          3.3          4.4
                                                TRACT DIAGNOSES AGE 0-17.
334............       12  SURG                 MAJOR MALE PELVIC                1.5888          4.3          5.0
                                                PROCEDURES W CC.
335............       12  SURG                 MAJOR MALE PELVIC                1.1891          3.3          3.5
                                                PROCEDURES W/O CC.
336............       12  SURG                 TRANSURETHRAL                     .8981          2.8          3.6
                                                PROSTATECTOMY W CC.
337............       12  SURG                 TRANSURETHRAL                     .6235          2.0          2.2
                                                PROSTATECTOMY W/O CC.

[[Page 24811]]

 
338............       12  SURG                 TESTES PROCEDURES, FOR           1.1598          3.3          5.1
                                                MALIGNANCY.
339............       12  SURG                 TESTES PROCEDURES, NON-          1.0637          2.9          4.5
                                                MALIGNANCY AGE >17.
340............       12  SURG                 *TESTES PROCEDURES, NON-          .2834          2.4          2.4
                                                MALIGNANCY AGE 0-17.
341............       12  SURG                 PENIS PROCEDURES..........       1.1125          2.1          3.2
342............       12  SURG                 CIRCUMCISION AGE >17......        .8606          2.6          3.5
343............       12  SURG                 *CIRCUMCISION AGE 0-17....        .1540          1.7          1.7
344............       12  SURG                 OTHER MALE REPRODUCTIVE          1.0994          1.6          2.4
                                                SYSTEM O.R. PROCEDURES
                                                FOR MALIGNANCY.
345............       12  SURG                 OTHER MALE REPRODUCTIVE           .8850          2.5          3.7
                                                SYSTEM O.R. PROC EXCEPT
                                                FOR MALIGNANCY.
346............       12  MED                  MALIGNANCY, MALE                  .9669          4.2          5.7
                                                REPRODUCTIVE SYSTEM, W CC.
347............       12  MED                  MALIGNANCY, MALE                  .5868          2.3          3.1
                                                REPRODUCTIVE SYSTEM, W/O
                                                CC.
348............       12  MED                  BENIGN PROSTATIC                  .6994          3.2          4.2
                                                HYPERTROPHY W CC.
349............       12  MED                  BENIGN PROSTATIC                  .4393          2.0          2.5
                                                HYPERTROPHY W/O CC.
350............       12  MED                  INFLAMMATION OF THE MALE          .6962          3.6          4.4
                                                REPRODUCTIVE SYSTEM.
351............       12  MED                  *STERILIZATION, MALE......        .2363          1.3          1.3
352............       12  MED                  OTHER MALE REPRODUCTIVE           .6762          2.7          3.9
                                                SYSTEM DIAGNOSES.
353............       13  SURG                 PELVIC EVISCERATION,             1.9662          5.4          7.1
                                                RADICAL HYSTERECTOMY &
                                                RADICAL VULVECTOMY.
354............       13  SURG                 UTERINE, ADNEXA PROC FOR         1.5142          4.8          5.8
                                                NON-OVARIAN/ADNEXAL MALIG
                                                W CC.
355............       13  SURG                 UTERINE, ADNEXA PROC FOR          .9471          3.2          3.4
                                                NON-OVARIAN/ADNEXAL MALIG
                                                W/O CC.
356............       13  SURG                 FEMALE REPRODUCTIVE SYSTEM        .7930          2.2          2.6
                                                RECONSTRUCTIVE PROCEDURES.
357............       13  SURG                 UTERINE & ADNEXA PROC FOR        2.3678          7.0          8.7
                                                OVARIAN OR ADNEXAL
                                                MALIGNANCY.
358............       13  SURG                 UTERINE & ADNEXA PROC FOR        1.2377          3.7          4.4
                                                NON-MALIGNANCY W CC.
359............       13  SURG                 UTERINE & ADNEXA PROC FOR         .8724          2.7          2.9
                                                NON-MALIGNANCY W/O CC.
360............       13  SURG                 VAGINA, CERVIX & VULVA            .8832          2.5          3.0
                                                PROCEDURES.
361............       13  SURG                 LAPAROSCOPY & INCISIONAL         1.1850          2.4          3.4
                                                TUBAL INTERRUPTION.
362............       13  SURG                 *ENDOSCOPIC TUBAL                 .3020          1.4          1.4
                                                INTERRUPTION.
363............       13  SURG                 D&C, CONIZATION & RADIO-          .7775          2.5          3.3
                                                IMPLANT, FOR MALIGNANCY.
364............       13  SURG                 D&C, CONIZATION EXCEPT FOR        .7605          2.6          3.5
                                                MALIGNANCY.
365............       13  SURG                 OTHER FEMALE REPRODUCTIVE        1.8299          4.9          7.1
                                                SYSTEM O.R. PROCEDURES.
366............       13  MED                  MALIGNANCY, FEMALE               1.2435          4.7          6.7
                                                REPRODUCTIVE SYSTEM W CC.
367............       13  MED                  MALIGNANCY, FEMALE                .5558          2.2          3.0
                                                REPRODUCTIVE SYSTEM W/O
                                                CC.
368............       13  MED                  INFECTIONS, FEMALE               1.0486          4.8          6.2
                                                REPRODUCTIVE SYSTEM.
369............       13  MED                  MENSTRUAL & OTHER FEMALE          .5540          2.4          3.2
                                                REPRODUCTIVE SYSTEM
                                                DISORDERS.
370............       14  SURG                 CESAREAN SECTION W CC.....       1.1037          4.5          6.0
371............       14  SURG                 CESAREAN SECTION W/O CC...        .7226          3.3          3.6
372............       14  MED                  VAGINAL DELIVERY W                .5785          2.6          3.3
                                                COMPLICATING DIAGNOSES.
373............       14  MED                  VAGINAL DELIVERY W/O              .4018          1.9          2.1
                                                COMPLICATING DIAGNOSES.
374............       14  SURG                 VAGINAL DELIVERY W                .7118          2.5          3.2
                                                STERILIZATION &/OR D&C.
375............       14  SURG                 *VAGINAL DELIVERY W O.R.          .6856          4.4          4.4
                                                PROC EXCEPT STERIL &/OR
                                                D&C.
376............       14  MED                  POSTPARTUM & POST ABORTION        .5246          2.4          3.5
                                                DIAGNOSES W/O O.R.
                                                PROCEDURE.
377............       14  SURG                 POSTPARTUM & POST ABORTION       1.3418          3.1          5.4
                                                DIAGNOSES W O.R.
                                                PROCEDURE.
378............       14  MED                  ECTOPIC PREGNANCY.........        .9321          2.3          2.8
379............       14  MED                  THREATENED ABORTION.......        .4438          2.1          3.1
380............       14  MED                  ABORTION W/O D&C..........        .3447          1.6          1.9
381............       14  SURG                 ABORTION W D&C, ASPIRATION        .5785          1.7          2.3
                                                CURETTAGE OR HYSTEROTOMY.
382............       14  MED                  FALSE LABOR...............        .2097          1.2          1.3
383............       14  MED                  OTHER ANTEPARTUM DIAGNOSES        .5250          2.8          4.0
                                                W MEDICAL COMPLICATIONS.
384............       14  MED                  OTHER ANTEPARTUM DIAGNOSES        .3457          1.8          2.4
                                                W/O MEDICAL COMPLICATIONS.
385............       15  ...................  *NEONATES, DIED OR               1.3760          1.8          1.8
                                                TRANSFERRED TO ANOTHER
                                                ACUTE CARE FACILITY.
386............       15  ...................  *EXTREME IMMATURITY OR           4.5376         17.9         17.9
                                                RESPIRATORY DISTRESS
                                                SYNDROME, NEONATE.
387............       15  ...................  *PREMATURITY W MAJOR             3.0991         13.3         13.3
                                                PROBLEMS.
388............       15  ...................  *PREMATURITY W/O MAJOR           1.8699          8.6          8.6
                                                PROBLEMS.

[[Page 24812]]

 
389............       15  ...................  *FULL TERM NEONATE W MAJOR       1.8398          4.7          4.7
                                                PROBLEMS.
390............       15  ...................  *NEONATE W OTHER                 1.6011          3.4          3.4
                                                SIGNIFICANT PROBLEMS.
391............       15  ...................  *NORMAL NEWBORN...........        .1526          3.1          3.1
392............       16  SURG                 SPLENECTOMY AGE >17.......       3.1400          7.2          9.7
393............       16  SURG                 *SPLENECTOMY AGE 0-17.....       1.3479          9.1          9.1
394............       16  SURG                 OTHER O.R. PROCEDURES OF         1.6743          4.1          6.8
                                                THE BLOOD AND BLOOD
                                                FORMING ORGANS.
395............       16  MED                  RED BLOOD CELL DISORDERS          .8170          3.3          4.6
                                                AGE >17.
396............       16  MED                  RED BLOOD CELL DISORDERS         1.0895          2.1          3.2
                                                AGE 0-17.
397............       16  MED                  COAGULATION DISORDERS.....       1.2145          3.9          5.4
398............       16  MED                  RETICULOENDOTHELIAL &            1.2525          4.7          6.0
                                                IMMUNITY DISORDERS W CC.
399............       16  MED                  RETICULOENDOTHELIAL &             .7076          3.0          3.7
                                                IMMUNITY DISORDERS W/O CC.
400............       17  SURG                 LYMPHOMA & LEUKEMIA W            2.6450          5.9          9.1
                                                MAJOR O.R. PROCEDURE.
401............       17  SURG                 LYMPHOMA & NON-ACUTE             2.6136          7.8         11.0
                                                LEUKEMIA W OTHER O.R.
                                                PROC W CC.
402............       17  SURG                 LYMPHOMA & NON-ACUTE             1.0641          2.8          4.2
                                                LEUKEMIA W OTHER O.R.
                                                PROC W/O CC.
403............       17  MED                  LYMPHOMA & NON-ACUTE             1.7141          5.7          8.0
                                                LEUKEMIA W CC.
404............       17  MED                  LYMPHOMA & NON-ACUTE              .8541          3.2          4.3
                                                LEUKEMIA W/O CC.
405............       17  ...................  *ACUTE LEUKEMIA W/O MAJOR        1.9110          4.9          4.9
                                                O.R. PROCEDURE AGE 0-17.
406............       17  SURG                 MYELOPROLIF DISORD OR            2.7825          7.5         10.1
                                                POORLY DIFF NEOPL W MAJ
                                                O.R. PROC W CC.
407............       17  SURG                 MYELOPROLIF DISORD OR            1.2467          3.4          4.2
                                                POORLY DIFF NEOPL W MAJ
                                                O.R. PROC W/O CC.
408............       17  SURG                 MYELOPROLIF DISORD OR            1.9957          4.7          7.8
                                                POORLY DIFF NEOPL W OTHER
                                                O.R. PROC.
409............       17  MED                  RADIOTHERAPY..............       1.0593          4.5          6.1
410............       17  MED                  CHEMOTHERAPY W/O ACUTE            .8997          2.8          3.6
                                                LEUKEMIA AS SECONDARY
                                                DIAGNOSIS.
411............       17  MED                  HISTORY OF MALIGNANCY W/O         .4177          1.8          2.3
                                                ENDOSCOPY.
412............       17  MED                  HISTORY OF MALIGNANCY W           .4028          1.5          2.0
                                                ENDOSCOPY.
413............       17  MED                  OTHER MYELOPROLIF DIS OR         1.3970          5.5          7.5
                                                POORLY DIFF NEOPL DIAG W
                                                CC.
414............       17  MED                  OTHER MYELOPROLIF DIS OR          .7882          3.1          4.2
                                                POORLY DIFF NEOPL DIAG W/
                                                O CC.
415............       18  SURG                 O.R. PROCEDURE FOR               3.5467         10.3         14.1
                                                INFECTIOUS & PARASITIC
                                                DISEASES.
416............       18  MED                  SEPTICEMIA AGE >17........       1.5004          5.6          7.3
417............       18  MED                  SEPTICEMIA AGE 0-17.......        .8818          3.6          4.9
418............       18  MED                  POSTOPERATIVE & POST-             .9925          4.8          6.1
                                                TRAUMATIC INFECTIONS.
419............       18  MED                  FEVER OF UNKNOWN ORIGIN           .8892          3.9          4.9
                                                AGE >17 W CC.
420............       18  MED                  FEVER OF UNKNOWN ORIGIN           .6151          3.0          3.7
                                                AGE >17 W/O CC.
421............       18  MED                  VIRAL ILLNESS AGE >17.....        .6676          3.1          3.9
422............       18  MED                  VIRAL ILLNESS & FEVER OF          .4797          2.4          3.0
                                                UNKNOWN ORIGIN AGE 0-17.
423............       18  MED                  OTHER INFECTIOUS &               1.6009          5.7          7.7
                                                PARASITIC DISEASES
                                                DIAGNOSES.
424............       19  SURG                 O.R. PROCEDURE W PRINCIPAL       2.3807          8.7         14.0
                                                DIAGNOSES OF MENTAL
                                                ILLNESS.
425............       19  MED                  ACUTE ADJUSTMENT REACTION         .6802          3.0          4.1
                                                & PSYCHOLOGICAL
                                                DYSFUNCTION.
426............       19  MED                  DEPRESSIVE NEUROSES.......        .5384          3.4          4.7
427............       19  MED                  NEUROSES EXCEPT DEPRESSIVE        .5750          3.4          5.0
428............       19  MED                  DISORDERS OF PERSONALITY &        .6910          4.4          6.8
                                                IMPULSE CONTROL.
429............       19  MED                  ORGANIC DISTURBANCES &            .8447          4.9          6.7
                                                MENTAL RETARDATION.
430............       19  MED                  PSYCHOSES.................        .7925          6.0          8.4
431............       19  MED                  CHILDHOOD MENTAL DISORDERS        .7467          4.7          7.0
432............       19  MED                  OTHER MENTAL DISORDER             .7113          3.3          5.2
                                                DIAGNOSES.
433............       20  ...................  ALCOHOL/DRUG ABUSE OR             .2974          2.3          3.1
                                                DEPENDENCE, LEFT AMA.
434............       20  ...................  ALC/DRUG ABUSE OR DEPEND,         .7290          3.9          5.2
                                                DETOX OR OTH SYMPT TREAT
                                                W CC.
435............       20  ...................  ALC/DRUG ABUSE OR DEPEND,         .4270          3.4          4.4
                                                DETOX OR OTH SYMPT TREAT
                                                W/O CC.
436............       20  ...................  ALC/DRUG DEPENDENCE W             .7934         10.7         13.6
                                                REHABILITATION THERAPY.
437............       20  ...................  ALC/DRUG DEPENDENCE,              .6899          7.5          9.0
                                                COMBINED REHAB & DETOX
                                                THERAPY.
438............  .......  ...................  NO LONGER VALID...........        .0000           .0           .0
439............       21  SURG                 SKIN GRAFTS FOR INJURIES..       1.6217          5.0          7.4
440............       21  SURG                 WOUND DEBRIDEMENTS FOR           1.9196          5.7          8.9
                                                INJURIES.

[[Page 24813]]

 
441............       21  SURG                 HAND PROCEDURES FOR               .9185          2.2          3.1
                                                INJURIES.
442............       21  SURG                 OTHER O.R. PROCEDURES FOR        2.2447          5.2          7.9
                                                INJURIES W CC.
443............       21  SURG                 OTHER O.R. PROCEDURES FOR         .9604          2.5          3.3
                                                INJURIES W/O CC.
444............       21  MED                  TRAUMATIC INJURY AGE >17 W        .7068          3.3          4.3
                                                CC.
445............       21  MED                  TRAUMATIC INJURY AGE >17 W/       .4796          2.4          3.0
                                                O CC.
446............       21  MED                  *TRAUMATIC INJURY AGE 0-17        .2962          2.4          2.4
447............       21  MED                  ALLERGIC REACTIONS AGE >17        .5218          1.9          2.5
448............       21  MED                  *ALLERGIC REACTIONS AGE 0-        .0974          2.9          2.9
                                                17.
449............       21  MED                  POISONING & TOXIC EFFECTS         .8140          2.6          3.7
                                                OF DRUGS AGE >17 W CC.
450............       21  MED                  POISONING & TOXIC EFFECTS         .4356          1.6          2.0
                                                OF DRUGS AGE >17 W/O CC.
451............       21  MED                  *POISONING & TOXIC EFFECTS        .2631          2.1          2.1
                                                OF DRUGS AGE 0-17.
452............       21  MED                  COMPLICATIONS OF TREATMENT        .9922          3.5          4.9
                                                W CC.
453............       21  MED                  COMPLICATIONS OF TREATMENT        .5065          2.2          2.9
                                                W/O CC.
454............       21  MED                  OTHER INJURY, POISONING &         .8161          3.2          4.5
                                                TOXIC EFFECT DIAG W CC.
455............       21  MED                  OTHER INJURY, POISONING &         .4661          1.9          2.6
                                                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         1.1304          2.4          4.5
                                                OTHER CONTACT W HEALTH
                                                SERVICES.
462............       23  MED                  REHABILITATION............       1.3558          9.8         12.4
463............       23  MED                  SIGNS & SYMPTOMS W CC.....        .6814          3.3          4.3
464............       23  MED                  SIGNS & SYMPTOMS W/O CC...        .4953          2.5          3.2
465............       23  MED                  AFTERCARE W HISTORY OF            .6710          2.0          3.6
                                                MALIGNANCY AS SECONDARY
                                                DIAGNOSIS.
466............       23  MED                  AFTERCARE W/O HISTORY OF          .6995          2.3          3.9
                                                MALIGNANCY AS SECONDARY
                                                DIAGNOSIS.
467............       23  MED                  OTHER FACTORS INFLUENCING         .5054          2.1          3.3
                                                HEALTH STATUS.
468............  .......  ...................  EXTENSIVE O.R. PROCEDURE         3.6495          9.4         13.3
                                                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            3.2312          4.9          5.6
                                                MAJOR JOINT PROCS OF
                                                LOWER EXTREMITY.
472............  .......  ...................  NO LONGER VALID...........        .0000           .0           .0
473............       17  ...................  ACUTE LEUKEMIA W/O MAJOR         3.7175          7.8         13.4
                                                O.R. PROCEDURE AGE >17.
474............  .......  ...................  NO LONGER VALID...........        .0000           .0           .0
475............       04  MED                  RESPIRATORY SYSTEM               3.7064          8.0         11.2
                                                DIAGNOSIS WITH VENTILATOR
                                                SUPPORT.
476............  .......  SURG                 PROSTATIC O.R. PROCEDURE         2.2619          8.6         11.7
                                                UNRELATED TO PRINCIPAL
                                                DIAGNOSIS.
477............  .......  SURG                 NON-EXTENSIVE O.R.               1.7659          5.3          8.0
                                                PROCEDURE UNRELATED TO
                                                PRINCIPAL DIAGNOSIS.
478............       05  SURG                 OTHER VASCULAR PROCEDURES        2.3493          5.0          7.3
                                                W CC.
479............       05  SURG                 OTHER VASCULAR PROCEDURES        1.4604          2.9          3.8
                                                W/O CC.
480............  .......  SURG                 LIVER TRANSPLANT..........      10.7204         17.6         23.1
481............  .......  SURG                 BONE MARROW TRANSPLANT....       8.6480         22.2         25.1
482............  .......  SURG                 TRACHEOSTOMY FOR FACE,           3.6326          9.9         12.9
                                                MOUTH & NECK DIAGNOSES.
483............  .......  SURG                 TRACHEOSTOMY EXCEPT FOR         15.9802         32.9         40.6
                                                FACE, MOUTH & NECK
                                                DIAGNOSES.
484............       24  SURG                 CRANIOTOMY FOR MULTIPLE          5.5399          9.0         13.3
                                                SIGNIFICANT TRAUMA.
485............       24  SURG                 LIMB REATTACHMENT, HIP AND       3.0215          7.4          9.1
                                                FEMUR PROC FOR MULTIPLE
                                                SIGNIFICANT TRA.
486............       24  SURG                 OTHER O.R. PROCEDURES FOR        4.8710          8.4         12.3
                                                MULTIPLE SIGNIFICANT
                                                TRAUMA.
487............       24  MED                  OTHER MULTIPLE SIGNIFICANT       1.9497          5.3          7.4
                                                TRAUMA.
488............       25  SURG                 HIV W EXTENSIVE O.R.             4.7592         12.0         18.2
                                                PROCEDURE.
489............       25  MED                  HIV W MAJOR RELATED              1.7870          6.1          8.7
                                                CONDITION.
490............       25  MED                  HIV W OR W/O OTHER RELATED        .9616          3.8          5.3
                                                CONDITION.
491............       08  SURG                 MAJOR JOINT & LIMB               1.6696          3.0          3.5
                                                REATTACHMENT PROCEDURES
                                                OF UPPER EXTREMITY.
492............       17  MED                  CHEMOTHERAPY W ACUTE             4.4339         11.4         16.8
                                                LEUKEMIA AS SECONDARY
                                                DIAGNOSIS.
493............       07  SURG                 LAPAROSCOPIC                     1.8341          4.3          5.7
                                                CHOLECYSTECTOMY W/O
                                                C.D.E. W CC.

[[Page 24814]]

 
494............       07  SURG                 LAPAROSCOPIC                     1.0276          2.0          2.5
                                                CHOLECYSTECTOMY W/O
                                                C.D.E. W/O CC.
495............  .......  SURG                 LUNG TRANSPLANT...........       9.1249         13.1         15.9
496............       08  SURG                 COMBINED ANTERIOR/               5.6734          8.4         10.8
                                                POSTERIOR SPINAL FUSION.
497............       08  SURG                 SPINAL FUSION W CC........       2.8425          4.9          6.3
498............       08  SURG                 SPINAL FUSION W/O CC......       1.7943          2.8          3.4
499............       08  SURG                 BACK & NECK PROCEDURES           1.4487          3.6          4.8
                                                EXCEPT SPINAL FUSION W CC.
500............       08  SURG                 BACK & NECK PROCEDURES            .9837          2.3          2.8
                                                EXCEPT SPINAL FUSION W/O
                                                CC.
501............       08  SURG                 KNEE PROCEDURES W PDX OF         2.5446          8.0         10.0
                                                INFECTION W CC.
502............       08  SURG                 KNEE PROCEDURES W PDX OF         1.5591          5.2          6.3
                                                INFECTION W/O CC.
503............       08  SURG                 KNEE PROCEDURES W/O PDX OF       1.2047          3.1          4.0
                                                INFECTION.
504............       22  SURG                 EXTENSIVE 3RD DEGREE BURNS      12.8853         23.5         31.1
                                                W SKIN GRAFT.
505............       22  MED                  EXTENSIVE 3RD DEGREE BURNS       2.1552          2.6          5.1
                                                W/O SKIN GRAFT.
506............       22  SURG                 FULL THICKNESS BURN W SKIN       4.1711         12.5         16.8
                                                GRAFT OR INHAL INJ W CC
                                                OR SIG TRAUMA.
507............       22  SURG                 FULL THICKNESS BURN W SKIN       1.8963          6.8          9.5
                                                GRFT OR INHAL INJ W/O CC
                                                OR SIG TRAUMA.
508............       22  MED                  FULL THICKNESS BURN W/O          1.5807          5.8          8.6
                                                SKIN GRFT OR INHAL INJ W
                                                CC OR SIG TRAUMA.
509............       22  MED                  FULL THICKNESS BURN W/O           .8575          3.9          5.4
                                                SKIN GRFT OR INH INJ W/O
                                                CC OR SIG TRAUMA.
510............       22  MED                  NON-EXTENSIVE BURNS W CC         1.3433          5.1          7.4
                                                OR SIGNIFICANT TRAUMA.
511............       22  MED                  NON-EXTENSIVE BURNS W/O CC        .8283          3.5          5.2
                                                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 presented for informational purposes only.
Note: Relative weights are based on medicare patient data and may not be appropriate for other patients.


                                   Table 7A.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
                                                        [FY98 MEDPAR Update 12/98 Grouper V16.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number        Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           36506          9.2605               2               4               7              12              19
2.......................................            7109          9.8658               3               5               7              12              20
3.......................................               7         10.5714               1               4              12              12              14
4.......................................            6015          7.4519               1               3               5               9              16
5.......................................           98703          3.4164               1               1               2               4               7
6.......................................             377          3.1326               1               1               2               4               7
7.......................................           11683          9.7496               2               4               7              12              19
8.......................................            3373          3.1254               1               1               2               4               7
9.......................................            1698          6.1143               1               3               5               8              12
10......................................           19098          6.5697               2               3               5               8              13
11......................................            3155          4.0396               1               2               3               5               8
12......................................           44239          6.2732               2               3               4               7              12
13......................................            6486          5.1576               2               3               4               6               9
14......................................          354618          6.0040               2               3               5               7              11
15......................................          143996          3.7354               1               2               3               5               7
16......................................           12049          5.9114               2               3               5               7              11
17......................................            3303          3.3657               1               2               3               4               6
18......................................           27014          5.4748               2               3               4               7              10
19......................................            7911          3.7895               1               2               3               5               7
20......................................            6115          9.9243               2               5               8              13              19
21......................................            1409          6.8027               2               3               5               9              13
22......................................            2567          4.9003               2               2               4               6               9
23......................................            7637          4.1747               1               2               3               5               8
24......................................           54321          5.0362               1               2               4               6              10
25......................................           24173          3.3500               1               2               3               4               6
26......................................              29          3.5862               1               1               3               4               6
27......................................            3593          5.2931               1               1               3               7              12
28......................................           11084          6.0999               1               3               5               8              12
29......................................            3704          3.6126               1               2               3               5               7
30......................................               1         13.0000              13              13              13              13              13
31......................................            3126          4.3349               1               2               3               5               8

[[Page 24815]]

 
32......................................            1388          2.6981               1               1               2               3               5
34......................................           19926          5.3284               1               2               4               6              10
35......................................            4860          3.4829               1               2               3               4               7
36......................................            4637          1.4238               1               1               1               1               2
37......................................            1545          3.8460               1               1               3               5               8
38......................................             106          2.6415               1               1               2               3               5
39......................................            1458          1.8759               1               1               1               2               4
40......................................            1967          3.3421               1               1               2               4               7
42......................................            3287          2.1150               1               1               1               2               4
43......................................              84          4.0476               1               2               2               4               7
44......................................            1346          4.9562               2               3               4               6               9
45......................................            2489          3.4339               1               2               3               4               6
46......................................            3035          4.5519               1               2               3               6               9
47......................................            1196          3.1304               1               1               2               4               6
48......................................               1          6.0000               6               6               6               6               6
49......................................            2268          5.0004               1               2               4               6              10
50......................................            2816          1.9950               1               1               1               2               3
51......................................             275          2.8873               1               1               1               3               7
52......................................             242          1.9463               1               1               1               2               3
53......................................            2676          3.6214               1               1               2               4               8
54......................................               1          1.0000               1               1               1               1               1
55......................................            1548          2.8443               1               1               2               3               6
56......................................             583          2.8405               1               1               2               3               6
57......................................             496          4.7702               1               1               3               5              12
59......................................              76          2.5921               1               1               2               3               6
60......................................               4          1.2500               1               1               1               1               2
61......................................             236          4.8051               1               1               3               6              10
62......................................               2          2.5000               2               2               3               3               3
63......................................            3257          4.4473               1               2               3               5               9
64......................................            3255          6.6224               1               2               4               8              14
65......................................           31668          2.9110               1               1               2               4               5
66......................................            6943          3.2093               1               2               3               4               6
67......................................             510          3.7118               1               2               3               4               7
68......................................           13096          4.1846               2               2               3               5               7
69......................................            4070          3.3174               1               2               3               4               6
70......................................              38          2.7368               1               2               2               3               5
71......................................             108          3.4259               1               2               3               4               6
72......................................             789          3.5349               1               2               3               4               7
73......................................            6418          4.3408               1               2               3               5               8
74......................................               1          2.0000               2               2               2               2               2
75......................................           40117          9.9090               3               5               7              12              19
76......................................           40189         11.0696               3               5               9              14              21
77......................................            2189          5.1092               1               2               4               7              10
78......................................           29868          7.0817               3               5               6               9              12
79......................................          203034          8.4200               3               4               7              10              16
80......................................            8367          5.5711               2               3               5               7              10
81......................................               9          6.1111               1               4               6               7               9
82......................................           67396          6.9696               2               3               5               9              14
83......................................            6816          5.4608               2               3               4               7              10
84......................................            1499          3.2115               1               2               3               4               6
85......................................           21440          6.5169               2               3               5               8              13
86......................................            1715          3.7638               1               2               3               5               7
87......................................           67211          6.2429               1               3               5               8              12
88......................................          395665          5.2571               2               3               4               7               9
89......................................          507777          6.1138               2               3               5               8              11
90......................................           46106          4.3389               2               3               4               5               7
91......................................              63          3.9683               1               2               3               5               7
92......................................           14068          6.2258               2               3               5               8              12
93......................................            1431          4.2851               1               2               4               6               8
94......................................           12904          6.3868               2               3               5               8              13
95......................................            1503          3.6334               1               2               3               4               7
96......................................           63347          4.7647               2               3               4               6               8
97......................................           28210          3.7386               1               2               3               5               7
98......................................              18          4.5000               2               2               3               4               5
99......................................           19288          3.1362               1               1               2               4               6
100.....................................            7679          2.1705               1               1               2               3               4

[[Page 24816]]

 
101.....................................           19908          4.4001               1               2               3               6               8
102.....................................            4712          2.7177               1               1               2               3               5
103.....................................             526         55.9620               9              15              38              81             125
104.....................................           32469         11.8910               3               6              10              15              22
105.....................................           28435          9.4345               4               6               7              11              17
106.....................................            3874         10.9174               5               7               9              13              18
107.....................................           96633         10.4780               5               7               9              12              17
108.....................................            5213         10.9714               3               6               9              14              21
109.....................................           66066          7.8103               4               5               7               9              13
110.....................................           58950          9.5307               2               5               8              11              18
111.....................................            6548          5.6188               2               4               6               7               8
112.....................................           80275          3.8243               1               1               3               5               8
113.....................................           45999         11.8933               3               5               9              15              23
114.....................................            8660          8.1865               2               4               7              10              16
115.....................................           14332          8.4104               2               4               7              11              16
116.....................................          270327          3.9279               1               1               3               5               8
117.....................................            3493          4.1457               1               1               3               5               9
118.....................................            6394          2.8907               1               1               2               4               6
119.....................................            1547          4.8946               1               1               3               6              11
120.....................................           36472          8.2124               1               2               5              11              18
121.....................................          168411          6.5102               2               4               5               8              12
122.....................................           83057          3.9825               1               2               4               5               7
123.....................................           41857          4.4094               1               1               2               6              10
124.....................................          144199          4.4338               1               2               3               6               8
125.....................................           69258          2.8460               1               1               2               4               6
126.....................................            5245         11.8471               3               6               9              15              23
127.....................................          720949          5.3848               2               3               4               7              10
128.....................................           13882          5.8857               3               4               5               7               9
129.....................................            4476          2.8132               1               1               1               3               7
130.....................................           93152          5.8377               2               3               5               7              10
131.....................................           26175          4.4798               1               3               4               6               7
132.....................................          166567          3.0916               1               2               2               4               6
133.....................................            7046          2.3686               1               1               2               3               4
134.....................................           32604          3.3402               1               2               3               4               6
135.....................................            7501          4.3393               1               2               3               5               8
136.....................................            1134          2.9365               1               1               2               4               6
138.....................................          203034          3.9942               1               2               3               5               8
139.....................................           74491          2.5373               1               1               2               3               5
140.....................................           89482          2.8042               1               1               2               3               5
141.....................................           85001          3.7313               1               2               3               5               7
142.....................................           40519          2.7087               1               1               2               3               5
143.....................................          173003          2.1910               1               1               2               3               4
144.....................................           77203          5.3186               1               2               4               7              11
145.....................................            6725          2.8174               1               1               2               4               5
146.....................................           12161         10.3049               5               7               9              12              17
147.....................................            2295          6.7115               3               5               7               8              10
148.....................................          142496         12.0975               5               7              10              14              21
149.....................................           16260          6.7259               4               5               6               8              10
150.....................................           22047         11.0292               4               6               9              14              19
151.....................................            4378          5.9826               2               3               6               8              11
152.....................................            4733          8.2766               3               5               7              10              14
153.....................................            1785          5.6112               3               4               5               7               8
154.....................................           32146         13.1977               4               7              10              16              25
155.....................................            5559          4.4970               1               2               4               6               8
156.....................................               5         10.6000               2               2              11              13              22
157.....................................            8532          5.5772               1               2               4               7              11
158.....................................            4386          2.6423               1               1               2               3               5
159.....................................           17279          4.9647               1               2               4               6              10
160.....................................           10447          2.7383               1               1               2               4               5
161.....................................           12543          4.1562               1               2               3               5               9
162.....................................            6726          1.9967               1               1               1               2               4
163.....................................               6          3.3333               1               3               3               5               5
164.....................................            5059          8.5274               4               5               7              10              14
165.....................................            1803          4.9434               2               3               5               6               8
166.....................................            3401          5.1541               2               3               4               6              10
167.....................................            2666          2.7817               1               2               2               3               5

[[Page 24817]]

 
168.....................................            1649          4.6731               1               2               3               6              10
169.....................................             857          2.4982               1               1               2               3               5
170.....................................           12092         11.1993               2               5               8              14              22
171.....................................            1053          4.7673               1               2               4               6               9
172.....................................           31897          6.9143               2               3               5               9              14
173.....................................            2312          3.7855               1               1               3               5               8
174.....................................          249000          4.8426               2               3               4               6               9
175.....................................           25202          2.9397               1               2               3               4               5
176.....................................           17587          5.2799               2               3               4               6              10
177.....................................           10522          4.4893               2               2               4               6               8
178.....................................            3593          3.1795               1               2               3               4               6
179.....................................           12330          6.1658               2               3               5               8              12
180.....................................           90227          5.3446               2               3               4               7              10
181.....................................           24379          3.4107               1               2               3               4               6
182.....................................          234882          4.3349               1               2               3               5               8
183.....................................           76735          2.9911               1               1               2               4               6
184.....................................              89          3.0225               1               1               2               3               7
185.....................................            4222          4.5246               1               2               3               6               9
186.....................................               7          3.2857               1               2               3               4               4
187.....................................             838          3.9224               1               2               3               5               8
188.....................................           75482          5.5481               1               2               4               7              11
189.....................................            9623          3.2219               1               1               2               4               6
190.....................................              66          5.5909               1               2               4               7               9
191.....................................            9649         14.1563               4               7              10              17              28
192.....................................             834          7.0432               2               4               6               9              12
193.....................................            6497         12.6191               5               7              10              15              23
194.....................................             742          6.5660               2               4               6               8              11
195.....................................            5896          9.9910               4               6               8              12              17
196.....................................            1262          5.6830               2               4               5               7               9
197.....................................           22829          8.6119               3               5               7              10              15
198.....................................            6333          4.5173               2               3               4               6               8
199.....................................            1863          9.6334               2               5               7              13              19
200.....................................            1177         11.0110               2               4               8              14              22
201.....................................            1502         14.0752               4               6              11              18              28
202.....................................           27309          6.5861               2               3               5               8              13
203.....................................           29813          6.7010               2               3               5               9              13
204.....................................           54942          5.9723               2               3               5               7              11
205.....................................           23086          6.3271               2               3               5               8              12
206.....................................            1713          4.1004               1               2               3               5               8
207.....................................           32550          5.1222               1               2               4               6              10
208.....................................            9792          2.9086               1               1               2               4               6
209.....................................          353744          5.1342               3               3               4               6               8
210.....................................          133786          6.7558               3               4               6               8              11
211.....................................           29098          4.9011               3               3               4               6               7
212.....................................               8          3.6250               1               2               4               5               5
213.....................................            7866          8.3354               2               4               6              10              17
216.....................................            6023          9.5177               2               4               7              12              19
217.....................................           19595         12.5727               3               5               9              15              26
218.....................................           22521          5.2767               2               3               4               6               9
219.....................................           19288          3.1965               1               2               3               4               5
220.....................................               4          9.2500               1               1               6              12              18
223.....................................           17769          2.5644               1               1               2               3               5
224.....................................            7897          2.0380               1               1               2               3               4
225.....................................            5773          4.4653               1               2               3               6               9
226.....................................            5252          5.9842               1               2               4               8              12
227.....................................            4296          2.7491               1               1               2               3               5
228.....................................            2550          3.5910               1               1               2               4               8
229.....................................            1137          2.4450               1               1               2               3               5
230.....................................            2280          4.7487               1               2               3               6              10
231.....................................           10903          4.6309               1               2               3               6              10
232.....................................             527          4.0892               1               1               2               5               9
233.....................................            4814          7.4909               2               3               5               9              16
234.....................................            2558          3.4461               1               2               3               4               7
235.....................................            5355          5.0045               1               2               4               6               9
236.....................................           39188          4.9057               1               3               4               6               9
237.....................................            1699          3.5621               1               2               3               4               6

[[Page 24818]]

 
238.....................................            7684          8.2965               3               4               6              10              16
239.....................................           55608          6.2447               2               3               5               8              12
240.....................................           12878          6.6378               2               3               5               8              13
241.....................................            3005          4.0090               1               2               3               5               7
242.....................................            2655          6.5646               2               3               5               8              13
243.....................................           83845          4.7270               1               3               4               6               9
244.....................................           12628          4.8210               1               3               4               6               9
245.....................................            4919          3.5727               1               2               3               4               7
246.....................................            1343          3.7312               1               2               3               5               7
247.....................................           14016          3.4163               1               2               3               4               7
248.....................................            8925          4.6222               1               2               4               6               9
249.....................................           10902          3.5356               1               1               2               4               7
250.....................................            3601          4.1172               1               2               3               5               8
251.....................................            2274          2.9081               1               1               2               4               5
253.....................................           18995          4.7535               1               3               4               6               9
254.....................................            9941          3.2011               1               2               3               4               6
256.....................................            5904          5.0899               1               2               4               6              10
257.....................................           19379          2.9197               1               2               2               3               5
258.....................................           16797          2.0623               1               1               2               2               3
259.....................................            3704          2.7608               1               1               2               3               6
260.....................................            4700          1.4715               1               1               1               2               2
261.....................................            1775          2.1808               1               1               1               3               4
262.....................................             645          3.9271               1               1               3               5               8
263.....................................           25880         11.3104               3               5               8              14              22
264.....................................            3815          7.0029               2               3               5               8              13
265.....................................            4082          6.9581               1               2               4               8              14
266.....................................            2523          3.3436               1               1               2               4               7
267.....................................             240          4.0833               1               1               3               5               9
268.....................................             873          3.7537               1               1               2               4               8
269.....................................            8758          7.8451               2               3               6              10              16
270.....................................            2727          3.0983               1               1               2               4               7
271.....................................           22440          7.0501               3               4               6               8              13
272.....................................            5622          6.2757               2               3               5               7              12
273.....................................            1342          4.3644               1               2               3               5               8
274.....................................            2431          6.4825               1               3               5               8              13
275.....................................             201          3.7612               1               1               2               5               8
276.....................................             989          4.4034               1               2               4               5               8
277.....................................           83986          5.7562               2               3               5               7              10
278.....................................           27530          4.4238               2               3               4               5               8
279.....................................              11          5.0909               1               3               4               5               8
280.....................................           14848          4.2196               1               2               3               5               8
281.....................................            6385          3.0641               1               1               3               4               6
282.....................................               1          3.0000               3               3               3               3               3
283.....................................            5325          4.7213               1               2               4               6               9
284.....................................            1773          3.1985               1               1               3               4               6
285.....................................            5979         10.5514               3               5               8              13              21
286.....................................            2145          6.6112               2               3               5               8              13
287.....................................            5999         10.4182               3               5               7              12              20
288.....................................            1972          5.7221               2               3               4               6               9
289.....................................            4787          3.0171               1               1               2               3               6
290.....................................            8532          2.4319               1               1               2               3               4
291.....................................              76          2.0132               1               1               1               2               3
292.....................................            4798         10.3558               2               4               8              13              21
293.....................................             318          4.9119               1               2               4               6              10
294.....................................           83797          4.7445               1               2               4               6               9
295.....................................            3416          3.8662               1               2               3               5               7
296.....................................          232852          5.2808               2               3               4               6              10
297.....................................           36465          3.5335               1               2               3               4               6
298.....................................              86          3.5116               1               1               2               4               7
299.....................................            1113          5.3998               1               2               4               7              11
300.....................................           16055          6.2361               2               3               5               8              12
301.....................................            2798          3.5647               1               2               3               4               7
302.....................................            7788          9.7017               5               6               7              11              17
303.....................................           19947          8.7442               4               5               7              10              15
304.....................................           12267          8.8996               2               4               7              11              18
305.....................................            2771          3.8964               1               2               3               5               7

[[Page 24819]]

 
306.....................................            9087          5.4264               1               2               3               7              12
307.....................................            2172          2.3596               1               1               2               3               4
308.....................................            8237          6.1412               1               2               4               8              13
309.....................................            4040          2.5252               1               1               2               3               5
310.....................................           25234          4.3353               1               2               3               5               9
311.....................................            7913          1.9368               1               1               1               2               4
312.....................................            1652          4.5745               1               1               3               6              10
313.....................................             636          2.4009               1               1               2               3               5
314.....................................               1          2.0000               2               2               2               2               2
315.....................................           28095          7.8214               1               2               5              10              17
316.....................................           93946          6.6586               2               3               5               8              13
317.....................................             787          3.1525               1               1               2               3               6
318.....................................            6040          5.9818               1               3               4               8              12
319.....................................             452          2.8496               1               1               2               4               6
320.....................................          182629          5.4053               2               3               4               7              10
321.....................................           26785          3.8728               2               2               3               5               7
322.....................................              66          3.7273               1               2               3               4               6
323.....................................           16620          3.2068               1               1               2               4               6
324.....................................            7588          1.9258               1               1               1               2               4
325.....................................            7746          3.8615               1               2               3               5               7
326.....................................            2359          2.6880               1               1               2               3               5
327.....................................               9          3.4444               1               2               3               6               6
328.....................................             682          3.7097               1               2               3               5               7
329.....................................             107          2.4579               1               1               1               3               5
331.....................................           44791          5.5053               1               3               4               7              11
332.....................................            4640          3.4358               1               1               3               4               7
333.....................................             264          4.4356               1               2               3               5              10
334.....................................           14143          5.0008               3               3               4               6               8
335.....................................           10325          3.5485               2               3               3               4               5
336.....................................           46390          3.6056               1               2               3               4               7
337.....................................           30864          2.2143               1               1               2               3               3
338.....................................            2138          5.1300               1               2               3               7              12
339.....................................            1797          4.5042               1               1               3               6              10
340.....................................               2          1.0000               1               1               1               1               1
341.....................................            4067          3.1913               1               1               2               3               6
342.....................................             874          3.4748               1               2               2               4               7
344.....................................            4100          2.3539               1               1               1               2               5
345.....................................            1230          3.7195               1               1               2               4               8
346.....................................            4931          5.7175               1               3               4               7              11
347.....................................             370          3.1595               1               1               2               4               7
348.....................................            3080          4.1844               1               2               3               5               8
349.....................................             591          2.5296               1               1               2               3               5
350.....................................            6519          4.3806               2               2               4               5               8
352.....................................             692          3.9263               1               1               3               5               7
353.....................................            2693          7.0791               3               4               5               8              13
354.....................................            8980          5.7827               3               3               4               7              10
355.....................................            5919          3.4087               2               3               3               4               5
356.....................................           28210          2.5548               1               2               2               3               4
357.....................................            6046          8.6508               3               5               7              10              16
358.....................................           24803          4.4161               2               3               3               5               7
359.....................................           29406          2.8913               2               2               3               3               4
360.....................................           17303          3.0327               1               2               3               3               5
361.....................................             473          3.3742               1               1               2               4               7
362.....................................               1          1.0000               1               1               1               1               1
363.....................................            3572          3.2900               1               2               2               3               7
364.....................................            1811          3.5400               1               1               2               4               7
365.....................................            2008          7.1116               2               3               5               9              15
366.....................................            4324          6.6751               1               3               5               8              14
367.....................................             466          3.0193               1               1               2               4               6
368.....................................            2756          6.2144               2               3               5               8              12
369.....................................            2740          3.2281               1               1               2               4               6
370.....................................            1120          5.9848               3               3               4               5               9
371.....................................            1192          3.6460               2               3               3               4               5
372.....................................             847          3.2621               1               2               2               3               5
373.....................................            3838          2.1449               1               2               2               2               3
374.....................................             134          3.1716               1               2               2               3               4

[[Page 24820]]

 
375.....................................               5          4.4000               1               1               5               5               9
376.....................................             199          3.4472               1               1               2               3               7
377.....................................              35          5.4000               1               1               3               5              13
378.....................................             173          2.7746               1               2               2               3               4
379.....................................             350          3.0914               1               1               2               3               6
380.....................................              87          1.8851               1               1               1               2               3
381.....................................             183          2.3005               1               1               1               3               5
382.....................................              54          1.2963               1               1               1               1               2
383.....................................            1486          3.9711               1               2               3               5               8
384.....................................             121          2.4132               1               1               2               3               5
385.....................................               1          2.0000               2               2               2               2               2
389.....................................               6          5.8333               1               5               5               7               7
390.....................................               9          3.3333               1               1               4               4               5
392.....................................            2630          9.6696               3               4               7              12              20
394.....................................            1779          6.8375               1               2               4               8              15
395.....................................           77187          4.5508               1               2               3               6               9
396.....................................              17          3.1765               1               1               2               4               6
397.....................................           19143          5.3427               1               2               4               7              11
398.....................................           18492          5.9583               2               3               5               7              11
399.....................................            1493          3.7173               1               2               3               5               7
400.....................................            7294          9.1058               2               3               6              11              20
401.....................................            6217         11.0227               2               5               8              14              22
402.....................................            1452          4.1887               1               1               3               5               9
403.....................................           36218          8.0041               2               3               6              10              16
404.....................................            4103          4.3359               1               2               3               6               9
406.....................................            2824         10.1331               3               5               8              13              21
407.....................................             667          4.1829               1               2               3               5               7
408.....................................            2404          7.7417               1               2               5              10              18
409.....................................            3746          6.1030               2               3               4               6              12
410.....................................           49872          3.5697               1               2               3               4               6
411.....................................              21          2.2857               1               1               2               3               4
412.....................................              28          2.0000               1               1               1               2               4
413.....................................            7391          7.4619               2               3               6              10              15
414.....................................             687          4.1499               1               2               3               5               9
415.....................................           42535         14.0456               4               6              11              17              28
416.....................................          213568          7.3051               2               4               6               9              14
417.....................................              41          4.7805               1               2               4               6              10
418.....................................           22297          6.0470               2               3               5               7              11
419.....................................           15835          4.9039               2               2               4               6               9
420.....................................            3029          3.6524               1               2               3               5               7
421.....................................           13089          3.9185               1               2               3               5               7
422.....................................              91          2.9890               1               1               2               4               6
423.....................................            9072          7.7017               2               3               6               9              16
424.....................................            1385         14.0072               2               5              10              17              27
425.....................................           15534          4.0610               1               2               3               5               8
426.....................................            4568          4.6421               1               2               3               6               9
427.....................................            1659          4.9458               1               2               3               6              11
428.....................................             855          6.7766               1               2               4               8              14
429.....................................           29447          6.5176               2               3               5               8              13
430.....................................           58875          8.3608               2               3               6              11              17
431.....................................             306          6.9869               1               3               5               8              13
432.....................................             438          5.2283               1               2               3               5              10
433.....................................            6312          3.1039               1               1               2               4               6
434.....................................           21675          5.1476               1               2               4               6              10
435.....................................           14502          4.3431               1               2               4               5               8
436.....................................            3279         13.5166               4               7              12              21              27
437.....................................           11570          8.9775               3               5               8              11              15
439.....................................            1183          7.4480               1               3               5               9              15
440.....................................            5298          8.9332               2               3               6              11              19
441.....................................             562          3.0498               1               1               2               4               7
442.....................................           15691          7.9084               1               3               6              10              16
443.....................................            3343          3.2767               1               1               2               4               7
444.....................................            5016          4.2845               1               2               3               5               8
445.....................................            2198          3.0100               1               1               2               4               6
447.....................................            4686          2.5378               1               1               2               3               5
448.....................................               2          1.5000               1               1               2               2               2

[[Page 24821]]

 
449.....................................           25965          3.6989               1               1               3               4               7
450.....................................            6281          2.0492               1               1               1               2               4
451.....................................               4          3.7500               1               1               2               4               8
452.....................................           22264          4.9182               1               2               3               6              10
453.....................................            4242          2.8868               1               1               2               4               5
454.....................................            5953          4.4749               1               2               3               5               9
455.....................................             974          2.6078               1               1               2               3               5
461.....................................            3446          4.5133               1               1               2               5              11
462.....................................           10911         12.2067               4               6              10              16              23
463.....................................           16562          4.2876               1               2               3               5               8
464.....................................            4467          3.1842               1               2               3               4               6
465.....................................             202          3.5693               1               1               1               4               7
466.....................................            1753          3.9395               1               1               2               4               8
467.....................................            1206          3.2629               1               1               2               4               6
468.....................................           59861         13.2552               3               6              10              17              26
471.....................................           11866          5.6302               3               3               5               6               9
473.....................................            7998         13.1317               2               3               7              19              33
475.....................................          109305         11.0583               2               5               9              15              22
476.....................................            5166         11.6465               2               6              10              15              21
477.....................................           26937          8.0048               1               3               6              10              17
478.....................................          118559          7.2875               1               3               5               9              15
479.....................................           21234          3.7671               1               2               3               5               7
480.....................................             446         23.0807               7              11              16              28              47
481.....................................             269         25.0632              11              19              23              30              40
482.....................................            6415         12.8803               4               7              10              15              23
483.....................................           42782         38.7045              14              21              32              48              70
484.....................................             392         13.2219               1               6              10              18              27
485.....................................            3148          9.0886               4               5               7              11              17
486.....................................            2027         12.1722               1               5              10              16              24
487.....................................            3604          7.3047               1               3               6               9              15
488.....................................             784         18.0982               3               7              13              23              37
489.....................................           14037          8.7084               2               3               6              11              18
490.....................................            4768          5.2685               1               2               4               7              10
491.....................................           11583          3.5480               2               2               3               4               6
492.....................................            2575         16.8287               4               5              12              27              35
493.....................................           55018          5.7173               1               3               5               7              11
494.....................................           26030          2.5108               1               1               2               3               5
495.....................................             130         15.9154               6               8              13              22              29
496.....................................            1095         10.7826               4               5               8              13              21
497.....................................           23026          6.2674               2               3               5               7              11
498.....................................           16601          3.4126               1               2               3               4               6
499.....................................           33369          4.8049               1               2               4               6               9
500.....................................           40659          2.7628               1               1               2               3               5
501.....................................            1974         10.0172               4               5               8              12              19
502.....................................             544          6.2702               3               4               5               7              11
503.....................................            5860          3.9602               1               2               3               5               7
504.....................................             121         31.1488               9              15              26              40              62
505.....................................             157          5.0446               1               1               2               6              11
506.....................................            1107         16.4625               4               7              13              22              33
507.....................................             410          9.4780               2               4               8              13              20
508.....................................            1102          7.4093               2               3               5               9              14
509.....................................             493          4.9270               1               2               3               6              11
510.....................................            1017          6.9646               2               3               5               8              15
511.....................................             301          4.7176               1               2               3               6               9
                                         ----------------
                                                11177104
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                   Table 7B.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
                                                        [FY98 MEDPAR Update 12/98 Grouper V17.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                              Number        Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................           36506          9.2605               2               4               7              12              19
2.......................................            7109          9.8658               3               5               7              12              20

[[Page 24822]]

 
3.......................................               7         10.5714               1               4              12              12              14
4.......................................            6015          7.4519               1               3               5               9              16
5.......................................           98703          3.4164               1               1               2               4               7
6.......................................             377          3.1326               1               1               2               4               7
7.......................................           11683          9.7496               2               4               7              12              19
8.......................................            3373          3.1254               1               1               2               4               7
9.......................................            1698          6.1143               1               3               5               8              12
10......................................           19098          6.5697               2               3               5               8              13
11......................................            3155          4.0396               1               2               3               5               8
12......................................           44239          6.2732               2               3               4               7              12
13......................................            6486          5.1576               2               3               4               6               9
14......................................          354510          6.0035               2               3               5               7              11
15......................................          143996          3.7354               1               2               3               5               7
16......................................           12049          5.9114               2               3               5               7              11
17......................................            3303          3.3657               1               2               3               4               6
18......................................           27014          5.4748               2               3               4               7              10
19......................................            7911          3.7895               1               2               3               5               7
20......................................            6115          9.9243               2               5               8              13              19
21......................................            1409          6.8027               2               3               5               9              13
22......................................            2567          4.9003               2               2               4               6               9
23......................................            7637          4.1747               1               2               3               5               8
24......................................           54321          5.0362               1               2               4               6              10
25......................................           24173          3.3500               1               2               3               4               6
26......................................              29          3.5862               1               1               3               4               6
27......................................            3593          5.2931               1               1               3               7              12
28......................................           11084          6.0999               1               3               5               8              12
29......................................            3704          3.6126               1               2               3               5               7
30......................................               1         13.0000              13              13              13              13              13
31......................................            3126          4.3349               1               2               3               5               8
32......................................            1388          2.6981               1               1               2               3               5
34......................................           19926          5.3284               1               2               4               6              10
35......................................            4860          3.4829               1               2               3               4               7
36......................................            4637          1.4238               1               1               1               1               2
37......................................            1545          3.8460               1               1               3               5               8
38......................................             106          2.6415               1               1               2               3               5
39......................................            1458          1.8759               1               1               1               2               4
40......................................            1967          3.3421               1               1               2               4               7
42......................................            3287          2.1150               1               1               1               2               4
43......................................              84          4.0476               1               2               2               4               7
44......................................            1346          4.9562               2               3               4               6               9
45......................................            2489          3.4339               1               2               3               4               6
46......................................            3035          4.5519               1               2               3               6               9
47......................................            1196          3.1304               1               1               2               4               6
48......................................               1          6.0000               6               6               6               6               6
49......................................            2268          5.0004               1               2               4               6              10
50......................................            2816          1.9950               1               1               1               2               3
51......................................             275          2.8873               1               1               1               3               7
52......................................             242          1.9463               1               1               1               2               3
53......................................            2676          3.6214               1               1               2               4               8
54......................................               1          1.0000               1               1               1               1               1
55......................................            1548          2.8443               1               1               2               3               6
56......................................             583          2.8405               1               1               2               3               6
57......................................             496          4.7702               1               1               3               5              12
59......................................              76          2.5921               1               1               2               3               6
60......................................               4          1.2500               1               1               1               1               2
61......................................             236          4.8051               1               1               3               6              10
62......................................               2          2.5000               2               2               3               3               3
63......................................            3257          4.4473               1               2               3               5               9
64......................................            3255          6.6224               1               2               4               8              14
65......................................           31668          2.9110               1               1               2               4               5
66......................................            6943          3.2093               1               2               3               4               6
67......................................             510          3.7118               1               2               3               4               7
68......................................           13096          4.1846               2               2               3               5               7
69......................................            4070          3.3174               1               2               3               4               6
70......................................              38          2.7368               1               2               2               3               5
71......................................             108          3.4259               1               2               3               4               6

[[Page 24823]]

 
72......................................             789          3.5349               1               2               3               4               7
73......................................            6418          4.3408               1               2               3               5               8
74......................................               1          2.0000               2               2               2               2               2
75......................................           40117          9.9090               3               5               7              12              19
76......................................           40189         11.0696               3               5               9              14              21
77......................................            2189          5.1092               1               2               4               7              10
78......................................           29868          7.0817               3               5               6               9              12
79......................................          203034          8.4200               3               4               7              10              16
80......................................            8367          5.5711               2               3               5               7              10
81......................................               9          6.1111               1               4               6               7               9
82......................................           67396          6.9696               2               3               5               9              14
83......................................            6816          5.4608               2               3               4               7              10
84......................................            1499          3.2115               1               2               3               4               6
85......................................           21440          6.5169               2               3               5               8              13
86......................................            1715          3.7638               1               2               3               5               7
87......................................           67211          6.2429               1               3               5               8              12
88......................................          395665          5.2571               2               3               4               7               9
89......................................          507777          6.1138               2               3               5               8              11
90......................................           46106          4.3389               2               3               4               5               7
91......................................              63          3.9683               1               2               3               5               7
92......................................           14068          6.2258               2               3               5               8              12
93......................................            1431          4.2851               1               2               4               6               8
94......................................           12904          6.3868               2               3               5               8              13
95......................................            1503          3.6334               1               2               3               4               7
96......................................           63347          4.7647               2               3               4               6               8
97......................................           28210          3.7386               1               2               3               5               7
98......................................              18          4.5000               2               2               3               4               5
99......................................           19288          3.1362               1               1               2               4               6
100.....................................            7679          2.1705               1               1               2               3               4
101.....................................           19908          4.4001               1               2               3               6               8
102.....................................            4712          2.7177               1               1               2               3               5
103.....................................             526         55.9620               9              15              38              81             125
104.....................................           32469         11.8910               3               6              10              15              22
105.....................................           28435          9.4345               4               6               7              11              17
106.....................................            3874         10.9174               5               7               9              13              18
107.....................................           96633         10.4780               5               7               9              12              17
108.....................................            5213         10.9714               3               6               9              14              21
109.....................................           66066          7.8103               4               5               7               9              13
110.....................................           58950          9.5307               2               5               8              11              18
111.....................................            6548          5.6188               2               4               6               7               8
112.....................................           80275          3.8243               1               1               3               5               8
113.....................................           45978         11.8914               3               5               9              15              23
114.....................................            8660          8.1865               2               4               7              10              16
115.....................................           14332          8.4104               2               4               7              11              16
116.....................................          270327          3.9279               1               1               3               5               8
117.....................................            3493          4.1457               1               1               3               5               9
118.....................................            6394          2.8907               1               1               2               4               6
119.....................................            1547          4.8946               1               1               3               6              11
120.....................................           36569          8.2082               1               2               5              11              18
121.....................................          168411          6.5102               2               4               5               8              12
122.....................................           83057          3.9825               1               2               4               5               7
123.....................................           41857          4.4094               1               1               2               6              10
124.....................................          144199          4.4338               1               2               3               6               8
125.....................................           69258          2.8460               1               1               2               4               6
126.....................................            5245         11.8471               3               6               9              15              23
127.....................................          720949          5.3848               2               3               4               7              10
128.....................................           13882          5.8857               3               4               5               7               9
129.....................................            4476          2.8132               1               1               1               3               7
130.....................................           93152          5.8377               2               3               5               7              10
131.....................................           26175          4.4798               1               3               4               6               7
132.....................................          166567          3.0916               1               2               2               4               6
133.....................................            7046          2.3686               1               1               2               3               4
134.....................................           32604          3.3402               1               2               3               4               6
135.....................................            7501          4.3393               1               2               3               5               8
136.....................................            1134          2.9365               1               1               2               4               6
138.....................................          203034          3.9942               1               2               3               5               8

[[Page 24824]]

 
139.....................................           74491          2.5373               1               1               2               3               5
140.....................................           89482          2.8042               1               1               2               3               5
141.....................................           85001          3.7313               1               2               3               5               7
142.....................................           40519          2.7087               1               1               2               3               5
143.....................................          173003          2.1910               1               1               2               3               4
144.....................................           77203          5.3186               1               2               4               7              11
145.....................................            6725          2.8174               1               1               2               4               5
146.....................................           12161         10.3049               5               7               9              12              17
147.....................................            2295          6.7115               3               5               7               8              10
148.....................................          142496         12.0975               5               7              10              14              21
149.....................................           16260          6.7259               4               5               6               8              10
150.....................................           22047         11.0292               4               6               9              14              19
151.....................................            4378          5.9826               2               3               6               8              11
152.....................................            4733          8.2766               3               5               7              10              14
153.....................................            1785          5.6112               3               4               5               7               8
154.....................................           32146         13.1977               4               7              10              16              25
155.....................................            5559          4.4970               1               2               4               6               8
156.....................................               5         10.6000               2               2              11              13              22
157.....................................            8532          5.5772               1               2               4               7              11
158.....................................            4386          2.6423               1               1               2               3               5
159.....................................           17279          4.9647               1               2               4               6              10
160.....................................           10447          2.7383               1               1               2               4               5
161.....................................           12543          4.1562               1               2               3               5               9
162.....................................            6726          1.9967               1               1               1               2               4
163.....................................               6          3.3333               1               3               3               5               5
164.....................................            5059          8.5274               4               5               7              10              14
165.....................................            1803          4.9434               2               3               5               6               8
166.....................................            3401          5.1541               2               3               4               6              10
167.....................................            2666          2.7817               1               2               2               3               5
168.....................................            1649          4.6731               1               2               3               6              10
169.....................................             857          2.4982               1               1               2               3               5
170.....................................           12092         11.1993               2               5               8              14              22
171.....................................            1053          4.7673               1               2               4               6               9
172.....................................           31897          6.9143               2               3               5               9              14
173.....................................            2312          3.7855               1               1               3               5               8
174.....................................          249000          4.8426               2               3               4               6               9
175.....................................           25202          2.9397               1               2               3               4               5
176.....................................           17587          5.2799               2               3               4               6              10
177.....................................           10522          4.4893               2               2               4               6               8
178.....................................            3593          3.1795               1               2               3               4               6
179.....................................           12330          6.1658               2               3               5               8              12
180.....................................           90227          5.3446               2               3               4               7              10
181.....................................           24379          3.4107               1               2               3               4               6
182.....................................          234882          4.3349               1               2               3               5               8
183.....................................           76735          2.9911               1               1               2               4               6
184.....................................              89          3.0225               1               1               2               3               7
185.....................................            4222          4.5246               1               2               3               6               9
186.....................................               7          3.2857               1               2               3               4               4
187.....................................             838          3.9224               1               2               3               5               8
188.....................................           75482          5.5481               1               2               4               7              11
189.....................................            9623          3.2219               1               1               2               4               6
190.....................................              66          5.5909               1               2               4               7               9
191.....................................            9649         14.1563               4               7              10              17              28
192.....................................             834          7.0432               2               4               6               9              12
193.....................................            6497         12.6191               5               7              10              15              23
194.....................................             742          6.5660               2               4               6               8              11
195.....................................            5896          9.9910               4               6               8              12              17
196.....................................            1262          5.6830               2               4               5               7               9
197.....................................           22829          8.6119               3               5               7              10              15
198.....................................            6333          4.5173               2               3               4               6               8
199.....................................            1863          9.6334               2               5               7              13              19
200.....................................            1177         11.0110               2               4               8              14              22
201.....................................            1502         14.0752               4               6              11              18              28
202.....................................           27309          6.5861               2               3               5               8              13
203.....................................           29813          6.7010               2               3               5               9              13
204.....................................           54942          5.9723               2               3               5               7              11

[[Page 24825]]

 
205.....................................           23086          6.3271               2               3               5               8              12
206.....................................            1713          4.1004               1               2               3               5               8
207.....................................           32550          5.1222               1               2               4               6              10
208.....................................            9792          2.9086               1               1               2               4               6
209.....................................          353674          5.1341               3               3               4               6               8
210.....................................          133764          6.7556               3               4               6               8              11
211.....................................           29096          4.9012               3               3               4               6               7
212.....................................               8          3.6250               1               2               4               5               5
213.....................................            7866          8.3354               2               4               6              10              17
216.....................................            6023          9.5177               2               4               7              12              19
217.....................................           19595         12.5727               3               5               9              15              26
218.....................................           22521          5.2767               2               3               4               6               9
219.....................................           19288          3.1965               1               2               3               4               5
220.....................................               4          9.2500               1               1               6              12              18
223.....................................           17769          2.5644               1               1               2               3               5
224.....................................            7897          2.0380               1               1               2               3               4
225.....................................            5773          4.4653               1               2               3               6               9
226.....................................            5252          5.9842               1               2               4               8              12
227.....................................            4296          2.7491               1               1               2               3               5
228.....................................            2550          3.5910               1               1               2               4               8
229.....................................            1137          2.4450               1               1               2               3               5
230.....................................            2280          4.7487               1               2               3               6              10
231.....................................           10903          4.6309               1               2               3               6              10
232.....................................             527          4.0892               1               1               2               5               9
233.....................................            4814          7.4909               2               3               5               9              16
234.....................................            2558          3.4461               1               2               3               4               7
235.....................................            5355          5.0045               1               2               4               6               9
236.....................................           39179          4.9058               1               3               4               6               9
237.....................................            1699          3.5621               1               2               3               4               6
238.....................................            7684          8.2965               3               4               6              10              16
239.....................................           55608          6.2447               2               3               5               8              12
240.....................................           12878          6.6378               2               3               5               8              13
241.....................................            3005          4.0090               1               2               3               5               7
242.....................................            2655          6.5646               2               3               5               8              13
243.....................................           83845          4.7270               1               3               4               6               9
244.....................................           12628          4.8210               1               3               4               6               9
245.....................................            4919          3.5727               1               2               3               4               7
246.....................................            1343          3.7312               1               2               3               5               7
247.....................................           14016          3.4163               1               2               3               4               7
248.....................................            8925          4.6222               1               2               4               6               9
249.....................................           10902          3.5356               1               1               2               4               7
250.....................................            3601          4.1172               1               2               3               5               8
251.....................................            2274          2.9081               1               1               2               4               5
253.....................................           18995          4.7535               1               3               4               6               9
254.....................................            9941          3.2011               1               2               3               4               6
256.....................................            5904          5.0899               1               2               4               6              10
257.....................................           19379          2.9197               1               2               2               3               5
258.....................................           16797          2.0623               1               1               2               2               3
259.....................................            3704          2.7608               1               1               2               3               6
260.....................................            4700          1.4715               1               1               1               2               2
261.....................................            1775          2.1808               1               1               1               3               4
262.....................................             645          3.9271               1               1               3               5               8
263.....................................           25866         11.3105               3               5               8              14              22
264.....................................            3810          7.0034               2               3               5               8              13
265.....................................            4082          6.9581               1               2               4               8              14
266.....................................            2523          3.3436               1               1               2               4               7
267.....................................             240          4.0833               1               1               3               5               9
268.....................................             873          3.7537               1               1               2               4               8
269.....................................            8758          7.8451               2               3               6              10              16
270.....................................            2727          3.0983               1               1               2               4               7
271.....................................           22440          7.0501               3               4               6               8              13
272.....................................            5622          6.2757               2               3               5               7              12
273.....................................            1342          4.3644               1               2               3               5               8
274.....................................            2431          6.4825               1               3               5               8              13
275.....................................             201          3.7612               1               1               2               5               8
276.....................................             989          4.4034               1               2               4               5               8

[[Page 24826]]

 
277.....................................           83986          5.7562               2               3               5               7              10
278.....................................           27530          4.4238               2               3               4               5               8
279.....................................              11          5.0909               1               3               4               5               8
280.....................................           14848          4.2196               1               2               3               5               8
281.....................................            6385          3.0641               1               1               3               4               6
282.....................................               1          3.0000               3               3               3               3               3
283.....................................            5325          4.7213               1               2               4               6               9
284.....................................            1773          3.1985               1               1               3               4               6
285.....................................            5979         10.5514               3               5               8              13              21
286.....................................            2145          6.6112               2               3               5               8              13
287.....................................            5999         10.4182               3               5               7              12              20
288.....................................            1972          5.7221               2               3               4               6               9
289.....................................            4787          3.0171               1               1               2               3               6
290.....................................            8532          2.4319               1               1               2               3               4
291.....................................              76          2.0132               1               1               1               2               3
292.....................................            4798         10.3558               2               4               8              13              21
293.....................................             318          4.9119               1               2               4               6              10
294.....................................           83797          4.7445               1               2               4               6               9
295.....................................            3416          3.8662               1               2               3               5               7
296.....................................          232852          5.2808               2               3               4               6              10
297.....................................           36465          3.5335               1               2               3               4               6
298.....................................              86          3.5116               1               1               2               4               7
299.....................................            1113          5.3998               1               2               4               7              11
300.....................................           16055          6.2361               2               3               5               8              12
301.....................................            2798          3.5647               1               2               3               4               7
302.....................................            7788          9.7017               5               6               7              11              17
303.....................................           19947          8.7442               4               5               7              10              15
304.....................................           12267          8.8996               2               4               7              11              18
305.....................................            2771          3.8964               1               2               3               5               7
306.....................................            9087          5.4264               1               2               3               7              12
307.....................................            2172          2.3596               1               1               2               3               4
308.....................................            8237          6.1412               1               2               4               8              13
309.....................................            4040          2.5252               1               1               2               3               5
310.....................................           25234          4.3353               1               2               3               5               9
311.....................................            7913          1.9368               1               1               1               2               4
312.....................................            1652          4.5745               1               1               3               6              10
313.....................................             636          2.4009               1               1               2               3               5
314.....................................               1          2.0000               2               2               2               2               2
315.....................................           28095          7.8214               1               2               5              10              17
316.....................................           93946          6.6586               2               3               5               8              13
317.....................................             787          3.1525               1               1               2               3               6
318.....................................            6040          5.9818               1               3               4               8              12
319.....................................             452          2.8496               1               1               2               4               6
320.....................................          182629          5.4053               2               3               4               7              10
321.....................................           26785          3.8728               2               2               3               5               7
322.....................................              66          3.7273               1               2               3               4               6
323.....................................           16620          3.2068               1               1               2               4               6
324.....................................            7588          1.9258               1               1               1               2               4
325.....................................            7746          3.8615               1               2               3               5               7
326.....................................            2359          2.6880               1               1               2               3               5
327.....................................               9          3.4444               1               2               3               6               6
328.....................................             682          3.7097               1               2               3               5               7
329.....................................             107          2.4579               1               1               1               3               5
331.....................................           44791          5.5053               1               3               4               7              11
332.....................................            4640          3.4358               1               1               3               4               7
333.....................................             264          4.4356               1               2               3               5              10
334.....................................           14143          5.0008               3               3               4               6               8
335.....................................           10325          3.5485               2               3               3               4               5
336.....................................           46390          3.6056               1               2               3               4               7
337.....................................           30864          2.2143               1               1               2               3               3
338.....................................            2138          5.1300               1               2               3               7              12
339.....................................            1797          4.5042               1               1               3               6              10
340.....................................               2          1.0000               1               1               1               1               1
341.....................................            4067          3.1913               1               1               2               3               6
342.....................................             874          3.4748               1               2               2               4               7
344.....................................            4100          2.3539               1               1               1               2               5

[[Page 24827]]

 
345.....................................            1230          3.7195               1               1               2               4               8
346.....................................            4931          5.7175               1               3               4               7              11
347.....................................             370          3.1595               1               1               2               4               7
348.....................................            3080          4.1844               1               2               3               5               8
349.....................................             591          2.5296               1               1               2               3               5
350.....................................            6519          4.3806               2               2               4               5               8
352.....................................             692          3.9263               1               1               3               5               7
353.....................................            2693          7.0791               3               4               5               8              13
354.....................................            8980          5.7827               3               3               4               7              10
355.....................................            5919          3.4087               2               3               3               4               5
356.....................................           28210          2.5548               1               2               2               3               4
357.....................................            6046          8.6508               3               5               7              10              16
358.....................................           24803          4.4161               2               3               3               5               7
359.....................................           29406          2.8913               2               2               3               3               4
360.....................................           17303          3.0327               1               2               3               3               5
361.....................................             473          3.3742               1               1               2               4               7
362.....................................               1          1.0000               1               1               1               1               1
363.....................................            3572          3.2900               1               2               2               3               7
364.....................................            1811          3.5400               1               1               2               4               7
365.....................................            2008          7.1116               2               3               5               9              15
366.....................................            4324          6.6751               1               3               5               8              14
367.....................................             466          3.0193               1               1               2               4               6
368.....................................            2756          6.2144               2               3               5               8              12
369.....................................            2740          3.2281               1               1               2               4               6
370.....................................            1120          5.9848               3               3               4               5               9
371.....................................            1192          3.6460               2               3               3               4               5
372.....................................             847          3.2621               1               2               2               3               5
373.....................................            3838          2.1449               1               2               2               2               3
374.....................................             134          3.1716               1               2               2               3               4
375.....................................               5          4.4000               1               1               5               5               9
376.....................................             199          3.4472               1               1               2               3               7
377.....................................              35          5.4000               1               1               3               5              13
378.....................................             173          2.7746               1               2               2               3               4
379.....................................             350          3.0914               1               1               2               3               6
380.....................................              87          1.8851               1               1               1               2               3
381.....................................             183          2.3005               1               1               1               3               5
382.....................................              54          1.2963               1               1               1               1               2
383.....................................            1486          3.9711               1               2               3               5               8
384.....................................             121          2.4132               1               1               2               3               5
385.....................................               1          2.0000               2               2               2               2               2
389.....................................               6          5.8333               1               5               5               7               7
390.....................................               9          3.3333               1               1               4               4               5
392.....................................            2630          9.6696               3               4               7              12              20
394.....................................            1779          6.8375               1               2               4               8              15
395.....................................           77187          4.5508               1               2               3               6               9
396.....................................              17          3.1765               1               1               2               4               6
397.....................................           19143          5.3427               1               2               4               7              11
398.....................................           18492          5.9583               2               3               5               7              11
399.....................................            1493          3.7173               1               2               3               5               7
400.....................................            7294          9.1058               2               3               6              11              20
401.....................................            6217         11.0227               2               5               8              14              22
402.....................................            1452          4.1887               1               1               3               5               9
403.....................................           36218          8.0041               2               3               6              10              16
404.....................................            4103          4.3359               1               2               3               6               9
406.....................................            2824         10.1331               3               5               8              13              21
407.....................................             667          4.1829               1               2               3               5               7
408.....................................            2404          7.7417               1               2               5              10              18
409.....................................            3746          6.1030               2               3               4               6              12
410.....................................           49872          3.5697               1               2               3               4               6
411.....................................              21          2.2857               1               1               2               3               4
412.....................................              28          2.0000               1               1               1               2               4
413.....................................            7391          7.4619               2               3               6              10              15
414.....................................             687          4.1499               1               2               3               5               9
415.....................................           42535         14.0456               4               6              11              17              28
416.....................................          213568          7.3051               2               4               6               9              14
417.....................................              41          4.7805               1               2               4               6              10

[[Page 24828]]

 
418.....................................           22297          6.0470               2               3               5               7              11
419.....................................           15835          4.9039               2               2               4               6               9
420.....................................            3029          3.6524               1               2               3               5               7
421.....................................           13089          3.9185               1               2               3               5               7
422.....................................              91          2.9890               1               1               2               4               6
423.....................................            9072          7.7017               2               3               6               9              16
424.....................................            1385         14.0072               2               5              10              17              27
425.....................................           15534          4.0610               1               2               3               5               8
426.....................................            4568          4.6421               1               2               3               6               9
427.....................................            1659          4.9458               1               2               3               6              11
428.....................................             855          6.7766               1               2               4               8              14
429.....................................           29435          6.5167               2               3               5               8              13
430.....................................           58875          8.3608               2               3               6              11              17
431.....................................             306          6.9869               1               3               5               8              13
432.....................................             438          5.2283               1               2               3               5              10
433.....................................            6312          3.1039               1               1               2               4               6
434.....................................           21675          5.1476               1               2               4               6              10
435.....................................           14502          4.3431               1               2               4               5               8
436.....................................            3279         13.5166               4               7              12              21              27
437.....................................           11570          8.9775               3               5               8              11              15
439.....................................            1183          7.4480               1               3               5               9              15
440.....................................            5298          8.9332               2               3               6              11              19
441.....................................             562          3.0498               1               1               2               4               7
442.....................................           15691          7.9084               1               3               6              10              16
443.....................................            3343          3.2767               1               1               2               4               7
444.....................................            5016          4.2845               1               2               3               5               8
445.....................................            2198          3.0100               1               1               2               4               6
447.....................................            4686          2.5378               1               1               2               3               5
448.....................................               2          1.5000               1               1               2               2               2
449.....................................           25965          3.6989               1               1               3               4               7
450.....................................            6281          2.0492               1               1               1               2               4
451.....................................               4          3.7500               1               1               2               4               8
452.....................................           22264          4.9182               1               2               3               6              10
453.....................................            4242          2.8868               1               1               2               4               5
454.....................................            5953          4.4749               1               2               3               5               9
455.....................................             974          2.6078               1               1               2               3               5
461.....................................            3446          4.5133               1               1               2               5              11
462.....................................           10911         12.2067               4               6              10              16              23
463.....................................           16562          4.2876               1               2               3               5               8
464.....................................            4467          3.1842               1               2               3               4               6
465.....................................             202          3.5693               1               1               1               4               7
466.....................................            1753          3.9395               1               1               2               4               8
467.....................................            1206          3.2629               1               1               2               4               6
468.....................................           59764         13.2659               3               6              10              17              26
471.....................................           11866          5.6302               3               3               5               6               9
473.....................................            7998         13.1317               2               3               7              19              33
475.....................................          109305         11.0583               2               5               9              15              22
476.....................................            5166         11.6465               2               6              10              15              21
477.....................................           26937          8.0048               1               3               6              10              17
478.....................................          118559          7.2875               1               3               5               9              15
479.....................................           21234          3.7671               1               2               3               5               7
480.....................................             446         23.0807               7              11              16              28              47
481.....................................             269         25.0632              11              19              23              30              40
482.....................................            6415         12.8803               4               7              10              15              23
483.....................................           42777         38.7018              14              21              32              48              70
484.....................................             392         13.2219               1               6              10              18              27
485.....................................            3148          9.0886               4               5               7              11              17
486.....................................            2027         12.1722               1               5              10              16              24
487.....................................            3604          7.3047               1               3               6               9              15
488.....................................             784         18.0982               3               7              13              23              37
489.....................................           14037          8.7084               2               3               6              11              18
490.....................................            4768          5.2685               1               2               4               7              10
491.....................................           11583          3.5480               2               2               3               4               6
492.....................................            2575         16.8287               4               5              12              27              35
493.....................................           55018          5.7173               1               3               5               7              11
494.....................................           26030          2.5108               1               1               2               3               5

[[Page 24829]]

 
495.....................................             130         15.9154               6               8              13              22              29
496.....................................            1095         10.7826               4               5               8              13              21
497.....................................           23026          6.2674               2               3               5               7              11
498.....................................           16601          3.4126               1               2               3               4               6
499.....................................           33369          4.8049               1               2               4               6               9
500.....................................           40659          2.7628               1               1               2               3               5
501.....................................            1974         10.0172               4               5               8              12              19
502.....................................             544          6.2702               3               4               5               7              11
503.....................................            5860          3.9602               1               2               3               5               7
504.....................................             121         31.1488               9              15              26              40              62
505.....................................             157          5.0446               1               1               2               6              11
506.....................................             966         16.7598               4               8              13              22              33
507.....................................             349          9.4413               2               4               8              13              19
508.....................................             599          8.5192               2               3               6               9              17
509.....................................             210          5.3000               1               2               4               7              10
510.....................................            1661          7.3323               2               3               5               9              16
511.....................................             645          5.1581               1               2               3               6              11
                                         ----------------
                                                11176836
--------------------------------------------------------------------------------------------------------------------------------------------------------


 Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
             and Rural Hospitals (Case Weighted) March 1999
------------------------------------------------------------------------
                        State                           Urban     Rural
------------------------------------------------------------------------
ALABAMA.............................................     0.373     0.377
ALASKA..............................................     0.507     0.732
ARIZONA.............................................     0.368     0.536
ARKANSAS............................................     0.478     0.452
CALFORNIA...........................................     0.369     0.472
COLORADO............................................     0.449     0.559
CONNECTICUT.........................................     0.500     0.505
DELAWARE............................................     0.495     0.453
DISTRICT OF COLUMBIA................................     0.519  ........
FLORIDA.............................................     0.378     0.387
GEORGIA.............................................     0.486     0.487
HAWAII..............................................     0.492     0.556
IDAHO...............................................     0.548     0.576
ILLINOIS............................................     0.443     0.543
INDIANA.............................................     0.559     0.596
IOWA................................................     0.506     0.629
KANSAS..............................................     0.420     0.627
KENTUCKY............................................     0.491     0.515
LOUISIANA...........................................     0.430     0.495
MAINE...............................................     0.615     0.570
MARYLAND............................................     0.764     0.821
MASSACHUSETTS.......................................     0.528     0.559
MICHIGAN............................................     0.469     0.580
MINNESOTA...........................................     0.518     0.591
MISSISSIPPI.........................................     0.472     0.488
MISSOURI............................................     0.423     0.506
MONTANA.............................................     0.501     0.559
NEBRASKA............................................     0.488     0.626
NEVADA..............................................     0.296     0.474
NEW HAMPSHIRE.......................................     0.575     0.595
NEW JERSEY..........................................     0.412  ........
NEW MEXICO..........................................     0.477     0.510
NEW YORK............................................     0.545     0.620
NORTH CAROLINA......................................     0.536     0.506
NORTH DAKOTA........................................     0.616     0.662
OHIO................................................     0.521     0.565
OKLAHOMA............................................     0.438     0.531
OREGON..............................................     0.545     0.593
PENNSYLVANIA........................................     0.407     0.531
PUERTO RICO.........................................     0.488     0.589
RHODE ISLAND........................................     0.590  ........
SOUTH CAROLINA......................................     0.453     0.455
SOUTH DAKOTA........................................     0.536     0.617
TENNESSEE...........................................     0.465     0.495
TEXAS...............................................     0.415     0.517
UTAH................................................     0.529     0.654
VERMONT.............................................     0.644     0.603
VIRGINA.............................................     0.473     0.494
WASHINGTON..........................................     0.590     0.660
WEST VIRGINIA.......................................     0.592     0.574
WISCONSIN...........................................     0.562     0.634
WYOMING.............................................     0.475     0.677
------------------------------------------------------------------------


    Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
                          Weighted) March 1999
------------------------------------------------------------------------
                             State                                Ratio
------------------------------------------------------------------------
ALABAMA.......................................................     0.047
ALASKA........................................................     0.066
ARIZONA.......................................................     0.042
ARKANSAS......................................................     0.051
CALIFORNIA....................................................     0.039
COLORADO......................................................     0.050
CONNECTICUT...................................................     0.039
DELAWARE......................................................     0.054
DISTRICT OF COLUMBIA..........................................     0.039
FLORIDA.......................................................     0.046
GEORGIA.......................................................     0.056
HAWAII........................................................     0.046
IDAHO.........................................................     0.060
ILLINOIS......................................................     0.043
INDIANA.......................................................     0.059
IOWA..........................................................     0.054
KANSAS........................................................     0.049
KENTUCKY......................................................     0.051
LOUISIANA.....................................................     0.053
MAINE.........................................................     0.040
MARYLAND......................................................     0.013
MASSACHUSETTS.................................................     0.056
MICHIGAN......................................................     0.045
MINNESOTA.....................................................     0.049
MISSISSIPPI...................................................     0.048
MISSOURI......................................................     0.048
MONTANA.......................................................     0.051
NEBRASKA......................................................     0.057
NEVADA........................................................     0.031
NEW HAMPSHIRE.................................................     0.066
NEW JERSEY....................................................     0.037
NEW MEXICO....................................................     0.045
NEW YORK......................................................     0.052
NORTH CAROLINA................................................     0.050
NORTH DAKOTA..................................................     0.075
OHIO..........................................................     0.052
OKLAHOMA......................................................     0.052
OREGON........................................................     0.050
PENNSYLVANIA..................................................     0.042
PUERTO RICO...................................................     0.049
RHODE ISLAND..................................................     0.035
SOUTH CAROLINA................................................     0.047
SOUTH DAKOTA..................................................     0.060
TENNESSEE.....................................................     0.055
TEXAS.........................................................     0.051
UTAH..........................................................     0.054
VERMONT.......................................................     0.051
VIRGINIA......................................................     0.060
WASHINGTON....................................................     0.066
WEST VIRGINIA.................................................     0.056
WISCONSIN.....................................................     0.056

[[Page 24830]]

 
WYOMING.......................................................     0.054
------------------------------------------------------------------------

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 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 hospital inpatient 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 hospital inpatient 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 preserving the Medicare Trust Fund.
    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 our 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 2000, on various hospital groups. 
We estimate the effects of individual policy changes by estimating 
payments per case while holding all other payment policies constant. 
We use the best data available, but we do not attempt to predict 
behavioral responses to our policy changes, and we do not make 
adjustments for future changes in such variables as admissions, 
lengths of stay, or case mix. As we have done in previous proposed 
rules, we are soliciting comments and information about the 
anticipated effects of these changes on hospitals and our 
methodology for estimating them.

IV. Hospitals Included in and Excluded From the Prospective Payment 
System

    The prospective payment systems for hospital inpatient operating 
and capital-related costs encompass nearly all general, short-term, 
acute care hospitals that participate in the Medicare program. There 
were 45 Indian Health Service hospitals in our database, which we 
excluded from the analysis due to the special characteristics of the 
prospective payment method for these hospitals. Among other short-
term, acute care hospitals, only the 50 such hospitals in Maryland 
remain excluded from the prospective payment system under the waiver 
at section 1814(b)(3) of the Act. Thus, as of February 1999, we have 
included 4,874 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 final policy 
changes on these hospitals are discussed below.

V. Impact on Excluded Hospitals and Units

    As of February 1999, there were 1,085 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. Broken down by speciality, there were 587 psychiatric, 
191 rehabilitation, 208 long-term care, 70 childrens', 19 Christian 
Science Sanatoria, and 10 cancer hospitals. In addition, there were 
1,494 psychiatric and 901 rehabilitation units in hospitals 
otherwise subject to the prospective payment system. These excluded 
units are also paid in accordance with Sec. 413.40. Under 
Sec. 413.40(a)(2)(i)(A), the target rate-of-increase ceiling is not 
applicable to the 36 specialty hospitals and units in Maryland that 
are paid in accordance with the waiver at section 1814(b)(3) of the 
Act.
    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 2000 would be between 0 and 2.6 percent, 
depending on the hospital's or unit's costs in relation to its limit 
for the most recent cost reporting period for which information is 
available.
    The impact on excluded hospitals and units of the 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.

VI. Quantitative Impact Analysis of the Proposed Policy Changes Under 
the Prospective Payment System for Operating Costs

A. Basis and Methodology of Estimates

    In this proposed rule, we are announcing policy changes and 
payment rate updates for the prospective payment systems for 
operating and capital-related costs. We estimate the total impact of 
these changes for FY 2000 payments compared to FY 1999 payments to 
be approximately a $250 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 1998 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

[[Page 24831]]

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 1998 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 2000 changes to the capital prospective 
payment system are discussed below in section VII of this Appendix.
    The proposed changes discussed separately below are the 
following:
     The effects of the annual reclassification of diagnoses 
and procedures and the recalibration of the DRG relative weights 
required by section 1886(d)(4)(C) of the Act.
     The effects of changes in hospitals' wage index values 
reflecting the wage index update (FY 1996 data).
     The effects of fully removing from the wage index the 
costs and hours associated with teaching physicians Part A, 
residents, and CRNAs; and the effects of our proposal to implement 
the first year of a 5-year phase-out of these costs, by calculating 
a wage index based on 20 percent of hospitals' average hourly wages 
after removing the costs and hours associated with teaching 
physicians, residents, and CRNAs, and 80 percent of hospitals' 
average hourly wages with these costs included.
     The effects of geographic reclassifications by the 
MGCRB that will be effective in FY 2000.
     The total change in payments based on FY 2000 policies 
relative to payments based on FY 1999 policies.
    To illustrate the impacts of the FY 2000 proposed changes, our 
analysis begins with a FY 2000 baseline simulation model using: the 
FY 1999 GROUPER (version 16.0); the FY 1999 wage index; and no MGCRB 
reclassifications. Outlier payments are set at 5.1 percent of total 
DRG plus outlier payments.
    Each proposed and statutory policy change is then added 
incrementally to this baseline model, finally arriving at an FY 2000 
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 1999 to FY 2000. Four factors have significant 
impacts here. The 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 2000 using the most recently forecasted 
hospital market basket increase for FY 2000 of 2.7 percent minus 1.8 
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 2.7 percent minus 1.8 
percentage points (for an update of 0.9 percent).
    A second significant factor that impacts changes in hospitals' 
payments per case from FY 1999 to FY 2000 is a change in MGCRB 
reclassification status from one year to the next. That is, 
hospitals reclassified in FY 1999 that are no longer reclassified in 
FY 2000 may have a negative payment impact going from FY 1999 to FY 
2000; conversely, hospitals not reclassified in FY 1999 that are 
reclassified in FY 2000 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 1999 will be 6.2 percent of actual 
total DRG payments. When the FY 1999 final rule was published, we 
projected FY 1999 outlier payments would be 5.1 percent of total DRG 
plus outlier payments, and the standardized amounts were reduced 
correspondingly. The effects of the higher than expected outlier 
payments during FY 1999 (as discussed in the Addendum to this 
proposed rule) are reflected in the analyses below comparing our 
current estimates of FY 1999 payments per case to estimated FY 2000 
payments per case.
    Fourth, payments per case in FY 1999 are reduced from FY 1999 
for hospitals that receive the IME or the DSH adjustments. Section 
1886(d)(5)(B)(ii) of the Act provides that the IME adjustment is 
reduced from approximately a 6.5 percent increase for every 10 
percent increase in a hospital's resident-to-bed ratio in FY 1999, 
to a 6.0 percent increase in FY 2000. Similarly, in accordance with 
section 1886(d)(5)(F)(ix) of the Act, the DSH adjustment for FY 2000 
is reduced by 3 percent from what would otherwise have been paid, 
compared to a 2 percent reduction for FY 1999.
    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 4,874 hospitals included in the analysis. This is 100 
fewer hospitals than were included in the impact analysis in the FY 
1999 final rule with comment period (63 FR 41106).
    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 2,712 
hospitals located in urban areas (MSAs or NECMAs) included in our 
analysis. Among these, there are 1,553 hospitals located in large 
urban areas (populations over 1 million), and 1,160 hospitals in 
other urban areas (populations of 1 million or fewer). In addition, 
there are 2,162 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 2000 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 
that the number of hospitals paid based on these categorizations 
(after consideration of geographic reclassifications) are 2,790, 
1,628, 1,161, and 2,085, 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) or 
receive DSH payments, or some combination of these two adjustments. 
There are 3,772 nonteaching hospitals in our analysis, 868 teaching 
hospitals with fewer than 100 residents, and 234 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 five rows examine the impacts of the proposed changes 
on rural hospitals by special payment groups (SCHs, rural referral 
centers (RRCs), and MDHs), as well as rural hospitals not receiving 
a special payment designation. The RRCs (151), SCHs (639), MDHs 
(353), and SCH and RRCs (58) shown here were not reclassified for 
purposes of the standardized amount. There are three SCHs that will 
be reclassified for the standardized amount in FY 2000 that, 
therefore, are not included in these rows.

[[Page 24832]]

    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 1997 
Medicare cost report files, if available (otherwise FY 1996 data are 
used). Data needed to determine ownership status or Medicare 
utilization percentages were unavailable for 37 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 
1999 and FY 2000, or for either of those 2 years, by urban and rural 
status. The next rows illustrate the overall number of FY 2000 
reclassifications, as well as the numbers of reclassified hospitals 
grouped by urban and rural location. The final row in Table I 
contains hospitals located in rural counties but deemed to be urban 
under section 1886(d)(8)(B) of the Act.

                                  Table I.--Impact Analysis of Changes for FY 2000 Operating Prospective Payment System
                                                         [Percent Changes in Payments Per Case]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                         Remove    Blended
                                                    Number of      Drg       New wage   GME and      wage     DRG & WI          MGCRB           All FY
                                                      hosps.     recalib.    date \3\     CRNA      index      changes     reclassification      2000
                                                       \1\         \2\                 costs \4\  costs \5\      \6\             \7\            changes
                                                       (0)         (1)         (2)        (3)        (4)         (5)             (6)              (7)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION):
    ALL HOSPITALS.................................      4,875         0.0         0.2        0.2        0.0         0.0             0.0             -0.6
    URBAN HOSPITALS...............................      2,712        -0.1         0.1        0.2        0.0        -0.2            -0.4             -0.8
        LARGE URBAN...............................      1,552        -0.1        -0.1        0.1        0.0        -0.4            -0.5             -1.0
        OTHER URBAN...............................      1,160        -0.1         0.4        0.4        0.1         0.1            -0.3             -0.3
    RURAL HOSPITALS...............................      2,162         0.2         0.8        0.4        0.1         0.9             2.5              0.9
BED SIZE (URBAN):
    0- 99 BEDS....................................        679         0.2        -0.1        0.3        0.1        -0.1            -0.5             -0.3
    100-199 BEDS..................................        918         0.1         0.1        0.3        0.1         0.0            -0.5             -0.3
    200-299 BEDS..................................        553         0.0         0.2        0.3        0.1         0.0            -0.4             -0.6
    300-499 BEDS..................................        423        -0.1         0.1        0.3        0.1        -0.2            -0.3             -0.8
    500 OR MORE BEDS..............................        139        -0.2        -0.1       -0.1        0.0        -0.5            -0.4             -2.0
BED SIZE (RURAL):
    0-49 BEDS.....................................      1,194         0.5         0.6        0.4        0.1         0.9             0.2              1.5
    50-99 BEDS....................................        581         0.3         0.7        0.4        0.1         0.8             0.9              1.1
    100-149 BEDS..................................        232         0.2         0.8        0.5        0.1         0.8             3.8              0.8
    150-199 BEDS..................................         85         0.1         1.0        0.4        0.1         1.0             4.3              1.1
    200 OR MORE BEDS..............................         70         0.0         0.9        0.4        0.1         0.8             4.2              0.0
URBAN BY CENSUS DIVISION:
    NEW ENGLAND...................................        149         0.0         0.5        0.1        0.0         0.3            -0.3             -0.6
    MIDDLE ATLANTIC...............................        416         0.0        -0.5       -0.3       -0.1        -0.8            -0.4             -2.0
    SOUTH ATLANTIC................................        401        -0.1         0.8        0.5        0.1         0.6            -0.4              0.2
    EAST NORTH CENTRAL............................        446        -0.1         0.7        0.0        0.0         0.4            -0.4             -0.3
    EAST SOUTH CENTRAL............................        157        -0.1         0.8        0.4        0.1         0.6            -0.4              0.1
    WEST NORTH CENTRAL............................        183        -0.1        -0.2        0.1        0.0        -0.5            -0.4             -1.0
    WEST SOUTH CENTRAL............................        343         0.0        -1.2        0.5        0.1        -1.4            -0.4             -2.0
    MOUNTAIN......................................        126        -0.1         0.3        0.2        0.0         0.0            -0.4             -0.3
    PACIFIC.......................................        444        -0.1        -0.3        0.7        0.1        -0.4            -0.4             -0.9
    PUERTO RICO...................................         47         0.2         0.9        0.3        0.1         0.9            -0.5              0.5
RURAL BY CENSUS DIVISION:
    NEW ENGLAND...................................         52         0.1         0.0        0.0        0.0        -0.2             2.3              0.2
    MIDDLE ATLANTIC...............................         81         0.2        -0.5        0.2        0.0        -0.5             2.2              0.0
    SOUTH ATLANTIC................................        285         0.2         1.7        0.6        0.1         1.8             2.7              0.8
    EAST NORTH CENTRAL............................        301         0.2         0.8        0.5        0.1         0.8             2.0              0.8
    EAST SOUTH CENTRAL............................        270         0.3         1.6        0.6        0.1         1.8             2.5              1.8
    WEST NORTH CENTRAL............................        490         0.2         1.2        0.2        0.0         1.2             2.3              1.6
    WEST SOUTH CENTRAL............................        338         0.3        -1.1        0.5        0.1        -0.9             3.5             -0.2
    MOUNTAIN......................................        201         0.3         0.5        0.3        0.1         0.5             2.0              1.4
    PACIFIC.......................................        139         0.2         0.4        0.5        0.1         0.4             1.9              0.4
    PUERTO RICO...................................          5         0.2         3.2        0.4        0.1         3.2             0.7              2.5
(BY PAYMENT CATEGORIES):
    URBAN HOSPITALS...............................      2,790        -0.1         0.1        0.2        0.0        -0.1            -0.3             -0.8
        LARGE URBAN...............................      1,628        -0.1        -0.1        0.1        0.0        -0.3            -0.4             -1.0
        OTHER URBAN...............................      1,161        -0.1         0.4        0.3        0.1         0.2            -0.3             -0.2
    RURAL HOSPITALS...............................      2,085         0.2         0.8        0.4        0.1         0.8             2.2              0.9
TEACHING STATUS:
    NON-TEACHING..................................      3,772         0.1         0.3        0.4        0.1         0.2             0.3              0.1
    LESS THAN 100 RESIDENTS.......................        868        -0.1         0.2        0.2        0.0        -0.1            -0.3             -0.6
    100+ RESIDENTS................................        234        -0.1        -0.1       -0.1        0.0        -0.4            -0.2             -2.0
DISPROPORTIONATE SHARE HOSPITALS (DSH):
    NON-DSH.......................................      3,048         0.0         0.3        0.3        0.1         0.1             0.2             -0.3
    URBAN DSH
        100 BEDS OR MORE..........................      1,365        -0.1         0.0        0.2        0.0        -0.2            -0.3             -0.9
        FEWER THAN 100 BEDS.......................         86         0.2        -0.3        0.5        0.1        -0.2            -0.5             -0.3
    RURAL DSH
        SOLE COMMUNITY (SCH)......................        153         0.4         0.8        0.4        0.1         1.0            -0.1              1.5
        REFERRAL CENTERS (RRC)....................         55         0.2         1.4        0.6        0.1         1.4             4.7              1.0
    OTHER RURAL DSH HOSPITALS
        100 BEDS OR MORE..........................         57         0.3         1.4        0.6        0.1         1.6             1.1             -0.1
        FEWER THAN 100 BEDS.......................        110         0.5         1.7        0.6        0.1         2.0             0.2              2.7
URBAN TEACHING AND DSH:
    BOTH TEACHING AND DSH.........................        703        -0.1         0.0        0.1        0.0        -0.3            -0.4             -1.0

[[Page 24833]]

 
    TEACHING AND NO DSH...........................        337        -0.1         0.2        0.1        0.0        -0.1            -0.3             -1.0
    NO TEACHING AND DSH...........................        748         0.0         0.1        0.5        0.1         0.0            -0.2             -0.1
    NO TEACHING AND NO DSH........................      1,002         0.0         0.2        0.3        0.1         0.1            -0.5             -0.3
RURAL HOSPITAL TYPES:
    NONSPECIAL STATUS HOSPITALS...................        884         0.3         1.1        0.6        0.1         1.3             1.1              0.9
    RRC...........................................        151         0.1         0.9        0.5        0.1         0.9             5.6              0.3
    SCH...........................................        639         0.3         0.3        0.2        0.0         0.4             0.3              1.2
    MDH...........................................        353         0.4         0.6        0.4        0.1         0.9             0.3              1.3
    SCH AND RRC...................................         58         0.1         0.3        0.2        0.0         0.2             2.2              1.4
TYPE OF OWNERSHIP:
    VOLUNTARY.....................................      2,838         0.0         0.1        0.2        0.0        -0.1            -0.1             -0.7
    PROPRIETARY...................................        743         0.0         0.1        0.4        0.1         0.0             0.0             -0.3
    GOVERNMENT....................................      1,256         0.1         0.6        0.4        0.1         0.5             0.2             -0.2
    UNKNOWN.......................................         37        -0.1        -0.3       -0.4       -0.1        -0.6            -0.2             -2.0
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT
 DAYS:
    0-25..........................................        372         0.0        -0.4        0.6        0.1        -0.5            -0.1             -2.0
    25-50.........................................      1,745        -0.1         0.0        0.2        0.0        -0.3            -0.2             -1.0
    50-65.........................................      1,893         0.0         0.3        0.2        0.0         0.2             0.1             -0.2
    OVER 65.......................................        822         0.1         0.7        0.3        0.1         0.6             0.3              0.2
    UNKNOWN.......................................         42        -0.1        -0.3       -0.4       -0.1        -0.6            -0.2             -2.0
HOSPITALS RECLASSIFIED BY THE MEDICARE GEOGRAPHIC
 REVIEW BOARD:
 
RECLASSIFICATION STATUS DURING FY 1999 AND FY
 2000:
    RECLASSIFIED DURING BOTH FY 1999 AND FY 2000..        373         0.1         0.6        0.4        0.1         0.5             5.6             -0.3
        URBAN.....................................         55         0.0         0.1        0.5        0.1         0.0             4.1             -2.0
        RURAL.....................................        318         0.1         0.8        0.4        0.1         0.7             6.3              0.5
    RECLASSIFIED DURING FY 2000 ONLY..............        131         0.0         1.2        0.3        0.1         1.0             3.3              4.5
        URBAN.....................................         30        -0.2         1.2        0.2        0.0         0.8             2.2              2.9
        RURAL.....................................        101         0.2         1.1        0.4        0.1         1.2             5.4              7.3
    RECLASSIFIED DURING FY 1999 ONLY..............        136         0.1         0.4        0.4        0.1         0.4            -0.7             -6.0
        URBAN.....................................         32        -0.1        -0.1        0.4        0.1        -0.3            -0.9             -6.0
        RURAL.....................................        104         0.3         1.0        0.5        0.1         1.1            -0.4             -5.0
FY 2000 RECLASSIFICATIONS:
    ALL RECLASSIFIED HOSPITALS....................        504         0.0         0.7        0.4        0.1         0.6             5.1              0.8
        STANDARDIZED AMOUNT ONLY..................         65         0.2         0.6        0.5        0.1         0.7             2.7             -0.7
        WAGE INDEX ONLY...........................        393         0.0         0.8        0.4        0.1         0.6             5.5              1.0
        BOTH......................................         46         0.1         0.4        0.4        0.1         0.3             3.8              0.2
        NONRECLASSIFIED...........................      4,344         0.0         0.1        0.2        0.0        -0.1            -0.5             -0.7
    ALL URBAN RECLASSIFIED........................         85        -0.1         0.5        0.3        0.1         0.3             3.4             -0.1
        STANDARDIZED AMOUNT ONLY..................         13         0.1        -0.4        0.5        0.1        -0.3             0.9             -4.0
        WAGE INDEX ONLY...........................         49        -0.2         0.8        0.3        0.1         0.5             4.3              0.5
        BOTH......................................         23         0.1        -0.2        0.4        0.1        -0.2             0.4             -0.9
        NONRECLASSIFIED...........................      2,627        -0.1         0.1        0.2        0.0        -0.2            -0.6             -0.9
    ALL RURAL RECLASSIFIED........................        419         0.1         0.8        0.4        0.1         0.8             6.1              1.4
        STANDARDIZED AMOUNT ONLY..................         52         0.2         1.3        0.6        0.1         1.4             4.0              1.9
        WAGE INDEX ONLY...........................        344         0.1         0.7        0.4        0.1         0.7             6.0              1.3
        BOTH......................................         23         0.1         1.4        0.4        0.1         1.3             9.3              1.8
        NONRECLASSIFIED...........................      1,717         0.3         0.8        0.4        0.1         0.9            -0.4              0.9
OTHER RECLASSIFIED HOSPITALS (SECTION                      26         0.2         0.7        0.6        0.1         0.8            -0.5            -9.0
 1886(d)(8)(B))...................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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 1998, and hospital cost report data are from reporting periods beginning in FY 1996 and FY 1997.
\2\ This column displays the payment impact of the recalibration of the DRG weights based on FY 1998 MedPAR data and the DRG reclassification changes,
  in accordance with section 1886(d)(4)(C) of the Act.
\3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1996 cost reports.
\4\ This column displays the impact of completely removing the costs and hours associated with teaching physicians Part A, residents, and CRNAs from the
  wage index calculation.
\5\ This column illustrates the payment impact of phasing out the costs and hours associated with teaching physicians Part A, residents, and CRNAs, by
  calculating the wage index by blending 20 percent of an average hourly wage after removing these costs with 80 percent of an average hourly wage
  without removing these costs.
\6\ 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 1, 2, 3, and 4, and the FY 2000 budget neutrality factor of 0.997393.
\7\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
  the FY 2000 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2000. Reclassification for
  prior years has no bearing on the payment impacts shown here.
\8\ This column shows changes in payments from FY 1999 to FY 2000. It incorporates all of the changes displayed in columns 5 and 6 (the changes
  displayed in columns 1, 2, and 4 are included in column 5). It also displays the impact of the FY 2000 update, changes in hospitals' reclassification
  status in FY 2000 compared to FY 1999, the difference in outlier payments from FY 1999 to FY 2000, and the reductions to payments through the IME and
  DSH adjustments taking effect during FY 2000. The sum of these columns may be different from the percentage changes shown here due to rounding and
  interactive effects.


[[Page 24834]]

B. Impact of the Proposed Changes to the DRG Reclassifications and 
Recalibration of Relative Weights (Column 1)

    In column 1 of Table I, we present the combined effects of the 
DRG reclassifications and recalibration, as discussed in section II 
of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of 
the Act requires us 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 1999 DRG relative 
weights (GROUPER version 16) to aggregate payments using the 
proposed FY 2000 DRG relative weights (GROUPER version 17). Overall 
payments are unaffected by the DRG reclassification and 
recalibration. Consistent with the minor changes we are proposing 
for the FY 2000 GROUPER, the redistributional impacts of DRG 
reclassifications and recalibration across hospital groups are very 
small (a 0.1 percent decrease for large and other urban hospitals; a 
0.2 percent increase for rural hospitals). Within hospital 
categories, the net effects for urban hospitals are small positive 
changes for small hospitals (a 0.2 percent increase for hospitals 
with fewer than 100 beds), and small decreases for larger hospitals 
(a 0.2 percent decrease for hospitals with more than 500 beds). 
Among rural hospitals, small hospital categories experience the 
largest increases, a 0.5 percent increase for hospitals with fewer 
than 50 beds.
    The breakdown by urban census division shows that the decrease 
among urban hospitals is spread across most census categories. 
Payments to urban hospitals in New England, the Middle Atlantic, and 
the West South Central census divisions are unchanged, while 
payments to urban hospitals in Puerto Rico rise by 0.2 percent. All 
rural hospital census divisions experience payment increases ranging 
from 0.1 percent for hospitals in New England, to 0.3 percent for 
hospitals in the East South Central, West South Central, and 
Mountain census divisions. All other divisions experience a 0.2 
percent increase.
    This pattern of payment increases for small hospitals and 
decreases for larger hospitals persists among other categories. 
Declines in the relative weights of several specific DRGs likely 
contribute to this trend. Among these DRGs, the relative weight for 
DRG 108 (Other Cardiothoracic Procedures), declined from 5.9764 in 
FY 1999 to 5.7505 in this proposed rule for FY 2000. Also, the 
relative weight for DRG 112 (Percutaneous Cardiovascular Procedures) 
declined from 1.9893 in FY 1999 to 1.9200 in this proposed rule for 
FY 2000. Although these cardiovascular procedures are not 
necessarily limited to very large hospitals, we would expect they 
are more likely to occur in larger hospitals. As the relative 
weights of DRGs predominantly occurring in large hospitals decline, 
the relative weights of other DRGs rise, leading to the small 
payment increases in hospitals less likely to be affected by the 
declines in the DRGs noted above.

C. Impact of Updating the Wage Data (Column 2)

    Section 1886(d)(3)(E) of the Act requires that, beginning 
October 1, 1993, we annually update the wage data used to calculate 
the wage index. In accordance with this requirement, the proposed 
wage index for FY 2000 is based on data submitted for hospital cost 
reporting periods beginning on or after October 1, 1995 and before 
October 1, 1996. As with the previous column, the impact of the new 
data on hospital payments is isolated by holding the other payment 
parameters constant in the two simulations. That is, column 2 shows 
the percentage changes in payments when going from a model using the 
FY 1999 wage index (effective for discharges on or after March 1, 
1999 (64 FR 9378)) based on FY 1995 wage data before geographic 
reclassifications to a model using the FY 2000 prereclassification 
wage index based on FY 1996 wage data.
    The wage data collected on the FY 1996 cost reports is similar 
to the data used in the calculation of the FY 1999 wage index. For 
example, the wage index values used here include all physician Part 
A costs (direct and contracted), resident costs, and CRNA costs. 
Also, as in the calculation for the FY 1999 wage index, contract 
labor costs and hours for top management positions are included, and 
the overhead costs allocated to patient care areas excluded from the 
calculation of the wage index are excluded as well.
    The results indicate that the new wage data have an overall 
impact of a 0.2 percent increase in hospital payments (prior to 
applying the budget neutrality factor, see column 5). Rural 
hospitals especially appear to benefit from the update. Their 
payments increase by 0.8 percent. These increases are attributable 
to relatively large increases in the wage index values for the rural 
areas of particular States; Arizona, Puerto Rico, and South Carolina 
all had increases greater than 6 percent in their 
prereclassification wage index values. At the same time, several 
States experience large declines due to moving to the FY 1996 wage 
data; Massachusetts, Texas, and Utah all had decreases greater than 
6 percent.
    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 (0.1 percent decrease). Urban West South Central 
hospitals experience a 1.0 percent decrease, largely due to a number 
of MSAs in Texas with prereclassified FY 2000 wage indexes that fall 
by 6 percent or more. We note that the wage data used for the 
proposed wage index are based upon the data available as of February 
22, 1999, and therefore, do not reflect revision requests received 
by the fiscal intermediaries after February 22, 1999. 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.
    The largest increases are seen in the rural census divisions. 
Rural Puerto Rico experiences the greatest positive impact, 3.2 
percent. Hospitals in three other census divisions receive positive 
impacts over 1.0 percent; South Atlantic at 1.7 percent, East South 
Central at 1.6 percent, and West North Central at 1.2 percent.

D. Impact of Removing Teaching Physicians' Part A, Residents', and 
CRNAs' Costs (Column 3)

    As discussed in section III.C of the preamble, we are proposing 
to revise the calculation of the wage index by phasing out the costs 
and hours associated with teaching physicians Part A, residents, and 
CRNAs. Although the proposed FY 2000 wage index is based upon a 
blend of 20 percent of hospitals' average hourly wages after 
removing these costs and 80 percent of average hourly wages 
calculated without removing these costs, this column displays the 
impacts on payments per case of completely removing these costs from 
the wage index calculation.
    As described above in section III.C.1 of the preamble, we 
determined teaching physician costs by first subtracting the costs 
and hours attributable to teaching physicians based upon the special 
survey data we collected for this purpose. If these data were not 
available from the survey for a particular teaching hospital, 80 
percent of the total physician Part A costs and hours for that 
hospital were removed, consistent with the recommendation of 
hospital (see discussion in section III.C.1 of the preamble). If a 
teaching hospital did not separately report its physician Part A 
costs on the cost report, the amount reported on Line 23, Column 1, 
of the Worksheet A was removed from the total wage data (as was an 
associated amount for hours). Resident and CRNA costs and hours were 
removed in their entirety, based upon the data separately attributed 
to these employees on the Worksheet S-3.
    Column 3 shows the payment impacts of completely removing these 
costs, relative to wage index values calculated based on the FY 1996 
wage data without removing these costs. The overall payment impact 
of completely removing these costs and hours from the wage index 
calculation would be a 0.2 percent increase in total payments (prior 
to applying budget neutrality). The FY 2000 proposed wage index is, 
however, based on a blended average hourly wage. The impacts of this 
blended approach are shown in column 4.
    The impact of removing these costs from the wage index 
calculation are generally positive across the majority of hospital 
categories. However, examining the impacts across urban and rural 
census divisions indicate that urban Middle Atlantic hospitals 
experience a 0.3 percent decrease. This effect is attributable to 
the concentration of teaching hospitals in this census division. The 
largest positive impact occurs in the

[[Page 24835]]

urban Pacific census division, a 0.7 percent payment increase.
    As noted above, the data used to prepare the proposed FY 2000 
wage index are subject to revision. In particular, in early February 
1999, we instructed the fiscal intermediaries to review the survey 
data on collected teaching physician costs. We have also extended 
the deadline for teaching hospitals to request revisions to their 
teaching physician survey data until June 7, 1999. The extent of 
these requests and the number of changes that are approved by the 
fiscal intermediaries may change the impacts in the final rule.

E. Impact of 5-Year Phase-Out of Teaching Physicians', Residents', 
and CRNA Costs (Column 4)

    As described above in section III.E of this preamble, the 
proposed FY 2000 wage index is calculated by blending 80 percent of 
hospitals' average hourly wages calculated without removing teaching 
physician Part A, residents, or CRNA costs (and hours); and 20 
percent of average hourly wages calculated after removing these 
costs (and hours). This constitutes the first year of a 5-year 
phase-out of these costs, where the proportion of the calculation 
based upon average hourly wages after removing these costs increases 
by 20 percentage points per year.
    This column shows the impact of the blended wage index relative 
to a wage index using FY 1996 wage data without removing costs or 
hours of teaching physicians Part A, residents, or CRNAs. The 
impacts in column 4 are minimal (an increase or decrease of 0.1 
percent). As expected, the hospital categories experiencing negative 
payment impacts in column 3 experience either negative 0.1 percent 
changes or no change here. The overall impact is 0.0 percent.
    The combined wage index changes in Table I are determined by 
summing the individual impacts in columns 2 and 4. For example, the 
urban West South Central census division loses 1.2 percent from the 
new wage data, and gains 0.1 percent from the blended wage index. 
Therefore, the combined impact of the proposed FY 2000 wage index 
for these hospitals is a 1.1 percent decrease.
    The following chart compares the shifts in wage index values for 
labor market areas for FY 2000 relative to FY 1999. This chart 
demonstrates the impact of the proposed changes for the FY 2000 wage 
index relative to the FY 1999 wage index. The majority of labor 
market areas (299) experience less than a 5 percent change. A total 
of 47 labor market areas experience an increase of more than 5 
percent with 14 having an increase greater than 10 percent. A total 
of 28 areas experience decreases of more than 5 percent. Of those, 7 
decline by 10 percent or more.

------------------------------------------------------------------------
                                           Number of labor market areas
  Percentage change in area wage index   -------------------------------
                 values                       FY 1999         FY 2000
------------------------------------------------------------------------
Increase more than 10 percent...........               9              14
Increase more than 5 percent and less                 29              33
 than 10 percent........................
Increase or decrease less than 5 percent             305             299
Decrease more than 5 percent and less                 28              21
 than 10 percent........................
Decrease more than 10 percent...........               0               7
------------------------------------------------------------------------

    Among urban hospitals, 169 would experience an increase of 
between 5 and 10 percent and 40 more than 10 percent. A total of 139 
rural hospitals have increases greater than 5 percent, but none 
greater than 10 percent. On the negative side, 130 urban hospitals 
and 187 rural hospitals have decreases in their wage index values of 
at least 5 percent but less than 10 percent. There are no rural 
hospitals with decreases greater than 10 percent, and 21 urban 
hospitals in this category. 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...........              40               0
Increase more than 5 percent and less                169             139
 than 10 percent........................
Increase or decrease less than 5 percent            2352            1836
Decrease more than 5 percent and less                130             187
 than 10 percent........................
Decrease more than 10 percent...........              21               0
------------------------------------------------------------------------

F. Combined Impact of DRG and Wage Index Changes--Including Budget 
Neutrality Adjustment (Column 5)

    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 simulated aggregate payments using the FY 1999 DRG 
relative weights and wage index to simulated aggregate payments 
using the proposed FY 2000 DRG relative weights and blended wage 
index. Based on this comparison, we computed a wage and 
recalibration budget neutrality factor of 0.997393. 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 5. The 0.0 percent impact for All Hospitals 
demonstrates that these changes, in combination with the budget 
neutrality factor, are budget neutral.
    For the most part, the changes in this column are the sum of the 
changes in columns 1, 2, and 4, minus approximately 0.3 percent 
attributable to the budget neutrality factor. There may be some 
variation of plus or minus 0.1 percent due to rounding.

G. Impact of MGCRB Reclassifications (Column 6)

    Our impact analysis to this point has assumed hospitals are paid 
on the basis of their actual geographic location (with the exception 
of ongoing policies that provide that certain hospitals receive 
payments on bases other than where they are geographically located, 
such as hospitals in rural counties that are deemed urban under 
section 1886(d)(8)(B) of the Act). The changes in column 6 reflect 
the per case payment impact of moving from this baseline to a 
simulation incorporating the MGCRB decisions for FY 2000. 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

[[Page 24836]]

qualifying for a DSH adjustment or to receive a higher DSH payment.
    The proposed FY 2000 wage index values incorporate all of the 
MGCRB's reclassification decisions for FY 2000. 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, 1999. 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 2000.
    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 0.994453 to ensure that the effects of 
reclassification are budget neutral. (See section II.A.4.b. of the 
Addendum to this proposed rule.)
    As a group, rural hospitals benefit from geographic 
reclassification. Their payments rise 2.5 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 0.5 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. 
The smallest increases among the rural census divisions is 0.7 
percent for Puerto Rico and 1.9 percent for Pacific. The largest 
increase is in rural West South Central, with an increase of 3.5 
percent.
    Among rural hospitals designated as RRCs, 127 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 4.2 percent increase in payments.
    Rural hospitals reclassified for FY 1999 and FY 2000 experience 
a 6.3 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 2000 only experience a 5.4 percent increase in 
payments, while rural hospitals reclassified for FY 1999 only 
experience a 0.4 percent decrease in payments. Urban hospitals 
reclassified for FY 1999 but not FY 2000 experience a 0.9 percent 
decline in payments overall. Urban hospitals reclassified for FY 
2000 but not for FY 1999 experience a 3.3 percent increase in 
payments.
    The FY 2000 Reclassification rows of Table I show the changes in 
payments per case for all FY 2000 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 9.3 percent increase in payments. In addition, rural 
hospitals reclassified just for the wage index receive a 6.0 percent 
payment increase. The overall impact on reclassified hospitals is to 
increase their payments per case by an average of 5.1 percent for FY 
2000.
    The reclassification of hospitals primarily affects payment to 
nonreclassified hospitals through changes in the wage index and the 
geographic reclassification budget neutrality adjustment required by 
section 1886(d)(8)(D) of the Act. Among hospitals that are not 
reclassified, the overall impact of hospital reclassifications is an 
average decrease in payments per case of about 0.5 percent. Rural 
nonreclassified hospitals decrease by 0.4 percent, and urban 
nonreclassified hospitals lose 0.6 percent (the amount of the budget 
neutrality offset).
    The foregoing analysis was based on MGCRB and HCFA Administrator 
decisions made by February 27, 1999. As previously noted, there may 
be changes to some MGCRB decisions through the appeals, review, and 
applicant withdrawal process. The outcome of these cases will be 
reflected in the analysis presented in the final rule.

H. All Changes (Column 7)

    Column 7 compares our estimate of payments per case, 
incorporating all changes reflected in this proposed rule for FY 
2000 (including statutory changes), to our estimate of payments per 
case in FY 1999. It includes the effects of the 0.9 percent update 
to the standardized amounts and the hospital-specific rates for SCHs 
and MDHs. It also reflects the 1.1 percentage point difference 
between the projected outlier payments in FY 2000 (5.1 percent of 
total DRG payments) and the current estimate of the percentage of 
actual outlier payments in FY 1999 (6.2 percent), as described in 
the introduction to this Appendix and the Addendum to this proposed 
rule.
    Additional changes affecting the difference between FY 1999 and 
FY 2000 payments are the reductions to the IME and DSH adjustments 
enacted by the Balanced Budget Act of 1997. 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 2000, IME is reduced to 
approximately a 6.0 percent rate of increase, and DSH is reduced by 
3 percent from what hospitals otherwise would receive. We estimate 
the overall effect of these statutory changes to be a 0.5 percent 
reduction in FY 2000 payments. For hospitals receiving both IME and 
DSH, the impact is estimated to be a 0.8 percent reduction in 
payments per case.
    We also note that column 8 includes the impacts of FY 2000 MGCRB 
reclassifications compared to the payment impacts of FY 1999 
reclassifications. Therefore, when comparing FY 2000 payments to FY 
1999, the percent changes due to FY 2000 reclassifications shown in 
column 6 need to be offset by the effects of reclassification on 
hospitals' FY 1999 payments (column 7 of Table 1, July 31, 1998 
final rule (63 FR 41106)). For example, the impact of MGCRB 
reclassifications on rural hospitals' FY 1999 payments was 
approximately a 2.7 percent increase, more than offsetting the 2.5 
percent increase in column 6 for FY 2000. Therefore, the net change 
in FY 2000 payments due to reclassification for rural hospitals is 
actually a decrease of 0.2 percent relative to FY 1999. However, 
last year's analysis contained a somewhat different set of 
hospitals, so this might affect the numbers slightly.
    There might also be interactive effects among the various 
factors comprising the payment system that we are not able to 
isolate. For these reasons, the values in column 7 may not equal the 
sum of the changes in columns 5 and 6, plus the other impacts that 
we are able to identify.
    The overall payment change from FY 1999 to FY 2000 for all 
hospitals is a 0.6 percent decrease. This reflects the 0.9 percent 
update for FY 2000, the 1.1 percent lower outlier payments in FY 
1999 compared to FY 1999 (5.1 percent compared to 6.2 percent); and 
the 0.5 percent reduction due to lower IME and DSH payments.
    Hospitals in urban areas experience a 0.8 percent drop in 
payments per case compared to FY 1999. The 0.4 percent negative 
impact due to reclassification is offset by an identical negative 
impact for FY 1999. The impact of reducing IME and DSH is a 0.6 
percent reduction in FY 2000 payments per case. Payment to hospitals 
in large urban areas are expected to fall 1.0 percent per case 
compared to 0.3 percent per case for hospitals in other urban areas.
    Hospitals in rural areas, meanwhile, experience a 0.9 percent 
payment increase. As discussed previously, this is primarily due to 
the positive effect due to the wage index and DRG changes (0.9 
percent increase).
    Among census divisions, urban Middle Atlantic and the West South 
Central display the largest negative impacts, 2.0 percent decrease 
in payments per case for hospitals in these two divisions. These 
negative impacts are primarily related to the relatively large 
decreases attributable to the proposed wage index. Hospitals in the 
South Atlantic and East South Central census divisions, along with 
Puerto Rico, are the only urban categories grouped by census 
division exhibiting increases in payments per case for FY 2000. 
Again, this appears to be related to the proposed FY 2000 wage 
index.
    The only rural census division to experience a negative payment 
impact is West South Central (0.2 percent fall), and as is generally 
the case, this appears to be related to a negative payment impact 
related to their FY 1996 wage data. The largest increases by rural 
hospitals are in Puerto Rico at 2.5 percent. Among rural census 
divisions, the largest increases are in the East South Central and 
West North Central, with 1.8 percent and 1.6 percent increases in 
their FY 2000 payments per case, respectively. As with the other 
impacts discussed above, this is generally due to updating the wage 
data. One rural census division that did not experience an increase 
in payments as large

[[Page 24837]]

as suggested by the positive impact of updating the wage data was 
the South Atlantic. This census division experienced a 3.8 percent 
payment increase due to geographic reclassification in FY 1999, but 
the effect of geographic reclassification in FY 2000 was only 2.7 
percent.
    Among special categories of rural hospitals, those hospitals 
receiving payment under the hospital-specific methodology (SCHs, 
MDHs, and SCH/RRCs) experience payment increases of 1.2 percent, 1.3 
percent, and 1.4 percent, respectively. This outcome is primarily 
related to the fact that, for hospitals receiving payments under the 
hospital-specific methodology, there are no outlier payments. 
Therefore, these hospitals do not experience negative payment 
impacts from the decline in outlier payments from FY 1999 to FY 2000 
(from 6.2 of total DRG plus outlier payments to 5.1 percent) as do 
hospitals paid based on the national standardized amounts.
    The largest negative payment impacts from FY 1999 to FY 2000 are 
among hospitals that were reclassified for FY 1999 and are not 
reclassified for FY 2000. Overall, these hospitals lose 6.0 percent. 
The urban hospitals in this category lose 6.0 percent, while the 
rural hospitals lose 5.0 percent. On the other hand, hospitals 
reclassified for FY 2000 that were not reclassified for FY 1999 
would experience the greatest payment increases: 4.5 percent 
overall; 7.3 percent for 101 rural hospitals in this category and 
2.9 percent for 32 urban hospitals.

              Table II--Impact Analysis of Changes for FY 2000 Operating Prospective Payment System
                                               [Payments Per Case]
----------------------------------------------------------------------------------------------------------------
                                                                  Average FY1999    Average FY
                                                     Number of      payment per    2000 payment     All changes
                                                     hospitals         case          per case
                                                             (1)           (2) 1           (3) 1             (4)
----------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION):
    ALL HOSPITALS...............................           4,875           6,770           6,730            -0.6
        URBAN HOSPITALS.........................           2,712           7,346           7,285            -0.8
        LARGE URBAN AREAS.......................           1,552           7,879           7,787            -1.2
    OTHER URBAN AREAS...........................           1,160           6,623           6,604            -0.3
    RURAL HOSPITALS.............................           2,162           4,505           4,546             0.9
BED SIZE (URBAN):
    0-99 BEDS...................................             679           4,973           4,957            -0.3
    100-199 BEDS................................             918           6,165           6,147            -0.3
    200-299 BEDS................................             553           6,998           6,958            -0.6
    300-499 BEDS................................             423           7,803           7,741            -0.8
    500 OR MORE BEDS............................             139           9,912           9,733            -1.8
BED SIZE (RURAL):
    0-49 BEDS...................................           1,194           3,725           3,779             1.5
    50-99 BEDS..................................             581           4,226           4,274             1.1
    100-149 BEDS................................             232           4,605           4,643             0.8
    150-199 BEDS................................              85           4,930           4,983             1.1
    200 OR MORE BEDS............................              70           5,734           5,733             0.0
URBAN BY CENSUS DIVISION:
    NEW ENGLAND.................................             149           7,723           7,677            -0.6
    MIDDLE ATLANTIC.............................             416           8,278           8,110            -2.0
    SOUTH ATLANTIC..............................             401           6,990           7,001             0.2
    EAST NORTH CENTRAL..........................             446           6,994           6,973            -0.3
    EAST SOUTH CENTRAL..........................             157           6,579           6,586             0.1
    WEST NORTH CENTRAL..........................             183           7,053           6,981            -1.0
    WEST SOUTH CENTRAL..........................             343           6,785           6,660            -1.8
    MOUNTAIN....................................             126           7,016           6,996            -0.3
    PACIFIC.....................................             444           8,460           8,388            -0.9
    PUERTO RICO.................................              47           3,108           3,124             0.5
RURAL BY CENSUS DIVISION:
    NEW ENGLAND.................................              52           5,356           5,369             0.2
    MIDDLE ATLANTIC.............................              81           4,862           4,860             0.0
    SOUTH ATLANTIC..............................             285           4,681           4,721             0.8
    EAST NORTH CENTRAL..........................             301           4,559           4,596             0.8
    EAST SOUTH CENTRAL..........................             270           4,162           4,239             1.8
    WEST NORTH CENTRAL..........................             490           4,279           4,349             1.6
    WEST SOUTH CENTRAL..........................             338           4,002           3,993            -0.2
    MOUNTAIN....................................             201           4,751           4,817             1.4
    PACIFIC.....................................             139           5,600           5,625             0.4
    PUERTO RICO.................................               5           2,334           2,392             2.5
(BY PAYMENT CATEGORIES):
    URBAN HOSPITALS.............................           2,790           7,310           7,251            -0.8
        LARGE URBAN.............................           1,628           7,806           7,715            -1.2
        OTHER URBAN.............................           1,161           6,610           6,596            -0.2
    RURAL HOSPITALS.............................           2,085           4,480           4,519             0.9
TEACHING STATUS:
    NON-TEACHING................................           3,772           5,473           5,477             0.1
    FEWER THAN 100 RESIDENTS....................             868           7,184           7,138            -0.6
    100 OR MORE RESIDENTS.......................             234          10,858          10,658            -1.8
DISPROPORTIONATE SHARE HOSPITALS (DSH):

[[Page 24838]]

 
    NON-DSH.....................................           3,048           5,792           5,775            -0.3
URBAN DSH:
    100 BEDS OR MORE............................           1,365           7,972           7,900            -0.9
    FEWER THAN 100 BEDS.........................              86           5,193           5,180            -0.3
RURAL DSH:
    SOLE COMMUNITY (SCH):.......................             153           4,205           4,266             1.5
    REFERRAL CENTERS (RRC)......................              55           5,357           5,408             1.0
OTHER RURAL DSH HOSPITALS:
    100 BEDS OR MORE............................              57           4,186           4,183            -0.1
    FEWER THAN 100 BEDS.........................             110           3,597           3,692             2.7
URBAN TEACHING AND DSH:
    BOTH TEACHING AND DSH.......................             703           8,936           8,826            -1.2
    TEACHING AND NO DSH.........................             337           7,281           7,211            -1.0
    NO TEACHING AND DSH.........................             748           6,371           6,362            -0.1
    NO TEACHING AND NO DSH......................           1,002           5,646           5,630            -0.3
RURAL HOSPITAL TYPES:
    NONSPECIAL STATUS HOSPITALS.................             884           3,964           3,997             0.9
    RRC.........................................             151           5,225           5,243             0.3
    SCH.........................................             639           4,470           4,524             1.2
    MDH.........................................             353           3,757           3,805             1.3
    SCH AND RRC.................................              58           5,368           5,442             1.4
TYPE OF OWNERSHIP:
    VOLUNTARY...................................           2,838           6,943           6,895            -0.7
    PROPRIETARY.................................             743           6,202           6,181            -0.3
    GOVERNMENT..................................           1,256           6,286           6,273            -0.2
    UNKNOWN.....................................              37           9,806           9,626            -1.8
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT
 DAYS:
    0-25........................................             372           8,826           8,692            -1.5
    25-50.......................................           1,745           7,924           7,844            -1.0
    50-65.......................................           1,893           5,997           5,986            -0.2
    OVER 65.....................................             822           5,272           5,285             0.2
    UNKNOWN.....................................              42           9,716           9,539            -1.8
HOSPITALS RECLASSIFIED BY THE MEDICARE
 GEOGRAPHIC REVIEW BOARD:
 
RECLASSIFICATION STATUS DURING FY 1999 AND FY
 2000:
    RECLASSIFIED DURING BOTH FY 1999 AND FY 2000             373           5,819           5,803            -0.3
        URBAN...................................              55           8,004           7,849            -1.9
        RURAL...................................             318           5,202           5,226             0.5
    RECLASSIFIED DURING FY 2000 ONLY............             131           6,183           6,459             4.5
    URBAN.......................................              30           8,096           8,327             2.9
        RURAL...................................             101           4,362           4,682             7.3
    RECLASSIFIED DURING FY 1999 ONLY............             136           5,577           5,267            -5.6
        URBAN...................................              32           6,976           6,568            -5.8
        RURAL...................................             104           4,611           4,369            -5.3
FY 2000 RECLASSIFICATIONS:
    ALL RECLASSIFIED HOSPITALS..................             504           5,896           5,943             0.8
        STANDARDIZED AMOUNT ONLY................              65           4,764           4,732            -0.7
        WAGE INDEX ONLY.........................             393           5,981           6,041             1.0
        BOTH....................................              46           6,156           6,168             0.2
        NONRECLASSIFIED.........................           4,344           6,889           6,839            -0.7
    ALL URBAN RECLASSIFIED......................              85           8,039           8,028            -0.1
        STANDARDIZED AMOUNT ONLY................              13           5,253           5,032            -4.2
        WAGE INDEX ONLY.........................              49           8,867           8,908             0.5
        BOTH....................................              23           6,894           6,834            -0.9
        NONRECLASSIFIED.........................           2,627           7,318           7,255            -0.9
    ALL RURAL RECLASSIFIED......................             419           5,075           5,144             1.4
        STANDARDIZED AMOUNT ONLY................              52           4,468           4,551             1.9
        WAGE INDEX ONLY.........................             344           5,110           5,175             1.3
        BOTH....................................              23           5,281           5,379             1.8
        NONRECLASSIFIED.........................           1,717           4,108           4,143             0.9
OTHER RECLASSIFIED HOSPITALS (SECTION                         26           4,781           4,361           -8.8
 1886(d)(8)(B)).................................
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.


[[Page 24839]]

    Table II presents the projected impact of the proposed changes 
for FY 2000 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 2000 with the average estimated per case 
payments for FY 1999, as calculated under our models. Thus, this 
table presents, in terms of the average dollar amounts paid per 
discharge, the combined effects of the changes presented in Table I. 
The percentage changes shown in the last column of Table II equal 
the percentage changes in average payments from column 7 of Table I.

VII. Impact of Proposed Changes in the Capital Prospective Payment 
System

A. General Considerations

    We now have cost report data for the 5th and 6th years of the 
capital prospective payment system (cost reports beginning in FY 
1996 and in FY 1997) available through the December 1998 update of 
the 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.
     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 2000 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 2000 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 2000. In 
addition, we have integrated sufficient hospital-specific 
information into our actuarial model to project the impact of the 
proposed FY 2000 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 
2000 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 2000 Actuarial Model

1. Assumptions

    In this impact analysis, we model dynamically the impact of the 
capital prospective payment system from FY 1999 to FY 2000 using a 
capital cost model. The FY 2000 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 1997 as 
reported on the December 1998 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, 1999 in the provider-specific file. We used these data to 
determine the proposed FY 2000 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 1997, 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 1997. All 
Federal rate payment parameters are assigned to the applicable 
hospital.
    For purposes of this impact analysis, the proposed FY 2000 
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
------------------------------------------------------------------------
1998........................................................       -0.71
1999........................................................       -0.15
2000........................................................        0.75
------------------------------------------------------------------------

     The Medicare case-mix index will increase by 1.0 
percent in FY 1999 and 0.5 percent in FY 2000.
     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 2000 update is -0.6 percent (see section IV of the 
Addendum to this proposed rule).

2. Results

    We have used the actuarial model to estimate the change in 
payment for capital-related costs from FY 1999 to FY 2000. 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:

[[Page 24840]]



 
                               Capital Transition Payment Methodology for FY 2000
----------------------------------------------------------------------------------------------------------------
                                                                                                    Percent of
                Type of Hospital                    Percent of      Percent of      Percent of        capital
                                                     hospitals      discharges     capital costs     payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital...............................              66              61              54              59
High Cost Hospital..............................              34              39              46              41
----------------------------------------------------------------------------------------------------------------

    A low capital cost hospital may request to have its hospital-
specific rate redetermined based on old capital costs in the current 
year, through the later of the hospital's cost reporting period 
beginning in FY 1994 or the first cost reporting period beginning 
after obligated capital comes into use (within the limits 
established in Sec. 412.302(e) for putting obligated capital into 
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 1999 to FY 
2000 using the above described actuarial model. With the proposed 
Federal rate, we estimate aggregate Medicare capital payments will 
increase by 2.66 percent in FY 2000.

                                      Table III.--Impact of Proposed Changes for FY 2000 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                             1999
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 1999 Payments per Discharge:
    Low Cost Hospitals.........................      3,200       6,737,171    $521.48      81.42     $58.83      $3.46       $8.72    $592.49
        Fully Prospective......................      2,977       6,138,720     511.78      80.00      64.57  .........        8.44     584.79  .........
        100% Federal Rate......................        193         538,418     642.90     100.00  .........  .........        4.44     647.34  .........
        Hold Harmless..........................         30          60,033     423.55      60.65  .........     388.55       75.12     887.21  .........
    High Cost Hospitals........................      1,634       4,248,111     658.19      97.70  .........      22.81       14.66     695.65  .........
        100% Federal Rate......................      1,424       3,876,299     677.27     100.00  .........  .........        7.26     684.53  .........
        Hold Harmless..........................        210         371,812     459.27      72.18  .........     260.63       91.71     811.60  .........
                                                --------------------------------------------------------------------------------------------------------
            Total Hospitals....................      4,834      10,985,282     574.34      87.91      36.08      10.94       11.01     632.38  .........
FY 2000 Payments per Discharge:
    Low Cost Hospitals.........................      3,200       6,785,508     573.45      90.60      29.15       2.91       10.29     615.79       3.93
        Fully Prospective......................      2,977       6,182,772     569.26      90.00      31.99  .........        9.24     610.48       4.39
        100% Federal Rate......................        194         543,519     632.85     100.00  .........  .........        4.51     637.36      -1.54
        Hold Harmless..........................         29          59,217     465.60      68.51  .........     333.70      173.36     972.66       9.63
    High Cost Hospitals........................      1,634       4,278,443     649.22      98.47  .........      16.61       24.44     690.27      -0.77
        100% Federal Rate......................      1,442       3,951,867     663.34     100.00  .........  .........       11.28     674.62      -1.45
        Hold Harmless..........................        192         326,576     478.35      78.33  .........     217.65      183.66     879.66       8.38
                                                --------------------------------------------------------------------------------------------------------
            Total Hospitals....................      4,834      11,063,951     602.75      93.72      17.87       8.21       15.76     644.59       1.93
--------------------------------------------------------------------------------------------------------------------------------------------------------

    We project that low capital cost hospitals paid under the fully 
prospective payment methodology will experience an average increase 
in payments per case of 4.39 percent, and high capital cost 
hospitals will experience an average decrease of 0.77 percent. These 
results are due to the change in the blended percentages to the 
payment system to 90 percent adjusted Federal rate and 10 percent 
hospital-specific rate.
    For hospitals paid under the fully prospective payment 
methodology, the Federal rate payment percentage will increase from 
80 percent to 90 percent and the hospital-specific rate payment 
percentage will decrease from 20 to 10 percent in FY 2000. 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 72.18 percent to 78.83 
percent. We estimate the percentage of hold-harmless hospitals paid 
based on 100 percent of the Federal rate will increase from 87.1 
percent to 88.2 percent. We estimate that the few remaining high 
cost hold-harmless hospitals (192) will experience an increase in 
payments of 8.38 percent from FY 1999 to FY 2000. The increase 
occurs because we estimate that exception payments per discharge 
will increase 50.1 percent from FY 1999 to FY 2000 for high cost 
hold-harmless hospitals. While we estimate that this group's regular 
hold-harmless payments for old capital will decline by 16.5 percent 
due to the retirement of old capital, we estimate that its high 
overall capital costs will cause an increase in these hospitals' 
exceptions payments from $91.71 per discharge in FY 1999 to $183.66 
per discharge in FY 2000. This is primarily due to the estimated 
decrease in outlier payments, which will cause an estimated increase 
in exceptions payments to cover unmet capital costs.
    We expect that the average hospital-specific rate payment per 
discharge will decrease from $64.57 in FY 1999 to $31.99 in FY 2000. 
This is mostly due to the decrease in the hospital-specific rate 
payment percentage from 20 percent in FY 1999 to 10 percent in FY 
2000.
    We are proposing no changes in our exceptions policies for FY 
2000. As a result, the minimum payment levels would be--

[[Page 24841]]

     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 1.74 
percent of total capital payments in FY 1999 to 2.45 percent of 
payments in FY 2000. The projected distribution of the exception 
payments is shown in the chart below:

                  Estimated FY 2000 Exceptions Payments
------------------------------------------------------------------------
                                                              Percent of
               Type of hospital                  Number of    exceptions
                                                 hospitals     payments
------------------------------------------------------------------------
Low Capital Cost..............................          180           40
High Capital Cost.............................          208           60
                                               -------------------------
    Total.....................................          388          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
                                                     number of      Percentage      Percentage      paid fully
                                                     hospitals      paid hold-      paid fully      prospective
                                                                   harmless  (A)   federal  (B)        rate
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals...............................           4,834             4.6            33.8            61.6
    Large urban areas (populations over 1                  1,531             4.8            41.7            53.4
     million)...................................
    Other urban areas (populations of 1 million            1,146             5.7            42.0            52.4
     of fewer)..................................
    Rural areas.................................           2,157             3.8            23.9            72.3
    Urban hospitals.............................           2,677             5.2            41.8            53.0
        0-99 beds...............................             650             6.5            34.3            59.2
        100-199 beds............................             912             7.2            48.5            44.3
        200-299 beds............................             553             4.2            42.3            53.5
        300-499 beds............................             423             1.4            39.2            59.3
        500 or more beds........................             139             1.4            39.6            59.0
    Rural hospitals.............................           2,157             3.8            23.9            72.3
        0-49 beds...............................           1,190             3.4            16.8            79.7
        50-99 beds..............................             580             4.5            29.5            66.0
        100-149 beds............................             232             4.7            36.6            58.6
        150-199 beds............................              85             3.5            30.6            65.9
        200 or more beds........................              70             1.4            48.6            50.0
By Region:
    Urban by Region.............................           2,677             5.2            41.8            53.0
        New England.............................             148             0.7            28.4            70.9
        Middle Atlantic.........................             412             2.7            36.4            60.9
        South Atlantic..........................             399             5.3            52.9            41.9
        East North Central......................             444             6.1            31.8            62.2
        East South Central......................             154            10.4            46.8            42.9
        West North Central......................             179             3.4            40.2            56.4
        West South Central......................             331            10.3            59.2            30.5
        Mountain................................             123             5.7            50.4            43.9
        Pacific.................................             440             3.4            36.6            60.0
        Puerto Rico.............................              47             2.1            27.7            70.2
    Rural by Region.............................           2,157             3.8            23.9            72.3
        New England.............................              52             1.9            23.1            75.0
        Middle Atlantic.........................              80             6.3            20.0            73.8
        South Atlantic..........................             285             1.4            34.7            63.9
        East North Central......................             300             3.3            18.3            78.3
        East South Central......................             270             2.6            34.1            63.3
        West North Central......................             490             3.7            15.9            80.4
        West South Central......................             337             3.9            27.9            68.2
        Mountain................................             200             8.5            18.0            73.5
        Pacific.................................             138             5.1            23.9            71.0
By Payment Classification:
    Large urban areas (populations over 1                  1,607             4.7            41.8            53.6
     million)...................................
    Other urban areas (populations of 1 million            1,147             5.8            41.3            52.9
     of fewer)..................................
    Rural areas.................................           2,080             3.8            23.6            72.5
    Teaching Status:
        Non-teaching............................           3,732             5.0            33.1            61.9
        Fewer than 100 Residents................             868             3.8            37.0            59.2
        100 or more Residents...................             234             1.3            33.3            65.4

[[Page 24842]]

 
        Disproportionate share hospitals (DSH):.
        Non-DSH.................................           3,014             4.6            29.9            65.5
        Urban DSH:
            100 or more beds....................           1,362             4.4            44.6            51.0
            Less than 100 beds..................              84             8.3            23.8            67.9
        Rural DSH:
            Sole Community (SCH)................             153             5.9            20.9            73.2
            Referral Center (RRC)...............              55             3.6            43.6            52.7
            Other Rural:........................
            100 or more beds....................              57             1.8            43.9            54.4
            Less than 100 beds..................             109             2.8            25.7            71.6
Urban teaching and DSH:
    Both teaching and DSH.......................             703             2.7            37.7            59.6
    Teaching and no DSH.........................             337             4.5            33.8            61.7
    No teaching and DSH.........................             743             6.5            48.7            44.8
    No teaching and no DSH......................             971             6.1            41.6            52.3
Rural Hospital Types:
    Non special status hospitals................             881             1.7            25.0            73.3
    RRC/EACH....................................             151             0.7            43.0            56.3
    SCH/EACH....................................             638             7.7            21.0            71.3
    Medicare-dependent hospitals (MDH)..........             352             2.3            16.2            81.5
    SCH, RRC and EACH...........................              58            12.1            25.9            62.1
Type of Ownership:
    Voluntary...................................           2,826             4.0            33.4            62.6
    Proprietary.................................             721             7.6            59.1            33.3
    Government..................................           1,255             3.8            20.8            75.4
Medicare Utilization as a Percent of Inpatient
 Days:
    0-25........................................             360             4.4            27.8            67.8
    25-50.......................................           1,739             4.8            36.6            58.7
    50-65.......................................           1,885             4.2            33.3            62.5
    Over 65.....................................             817             4.7            32.9            62.4
----------------------------------------------------------------------------------------------------------------

    As we explain in Appendix B of this proposed rule, we were not 
able to determine a hospital-specific rate for 40 of the 4,874 
hospitals in our database. Consequently, the payment methodology 
distribution is based on 4,834 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 33.8 percent in FY 2000.
    Table IV indicates that 61.6 percent of hospitals will be paid 
under the fully prospective payment methodology. (This figure, 
unlike the figure of 66 percent for low cost capital hospitals in 
the chart on ``Capital Transition Payment Methodology for FY 2000,'' 
in section VII.B.2. of this preamble takes into account 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 (72.5 percent and 75.4 percent, respectively 
by payment classification) are being paid under the fully 
prospective payment methodology. This is a reflection of their lower 
than average capital costs per case. In contrast, only 33.3 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 2000 actuarial model to estimate the potential 
impact of our proposed changes for FY 2000 on total capital payments 
per case, using a universe of 4,834 hospitals. The individual 
hospital payment parameters are taken from the best available data, 
including: the January 1, 1999 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 proposed FY 2000 payment policies. Columns 3 and 4 show 
estimates of payments per case under our model for FY 1999 and FY 
2000. Column 5 shows the total percentage change in payments from FY 
1999 to FY 2000. 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 1.0 
percent decrease in the Federal rate, a 0.5 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

[[Page 24843]]

of all other changes, including the change from 80 percent to 90 
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 1.9 percent in FY 2000, despite 
the effect of the 1.4 percent decrease attributable to the reduction 
in the Federal rate and other factors (which include changes in the 
adjustment to the Federal rate, the increase in case mix, and the 
other components of column 6 of table V).
    Our comparison by geographic location shows that urban and rural 
hospitals will experience slightly different rates of increase in 
capital payments per case (1.8 percent and 2.8 percent, 
respectively). This difference is due to the higher rate of decrease 
for urban hospitals relative to rural hospitals (1.6 percent and 0.4 
percent, respectively) from the Federal rate changes alone. Urban 
hospitals will gain approximately the same as rural hospitals (3.4 
percent versus 3.2 percent) from the effects of all other changes.
    Most 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 80 to 90 percent). Changes 
by region vary from a low of 1.1 percent decrease (West South 
Central urban region) to a high of 5.9 percent increase (West North 
Central rural region).
    By type of ownership, government hospitals are projected to have 
the largest rate of increase of total payment changes (3.1 percent, 
a 3.9 percent increase from the effects of all other changes and a 
0.8 percent decrease due to Federal rate changes). Payments to 
voluntary hospitals will increase 1.9 percent (a 3.3 percent 
increase from the effects of all other changes and a 1.4 percent 
decrease due to Federal rate changes), and payments to proprietary 
hospitals will increase 1.1 percent (a 3.1 percent increase from the 
effects of all other changes and a 2.0 percent decrease due to 
Federal rate 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 2000 compared to the effects of reclassification for FY 1999, we 
show the average payment percentage increase for hospitals 
reclassified in each fiscal year and in total. For FY 2000 
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 2000 as a whole are projected to 
experience a 2.8 percent increase in payments (a 3.1 percent 
increase attributable to the effects of all other changes and a 0.3 
percent decrease attributable to Federal rate changes). Payments to 
nonreclassified hospitals will increase slightly less (1.9 percent) 
than reclassified hospitals (2.8 percent) overall. Payments to 
nonreclassified hospitals will decrease more than reclassified 
hospitals from the Federal rate changes (1.5 percent compared to 0.3 
percent), but they will gain about the same from the effects of all 
other changes (3.4 percent compared to 3.1 percent).

                                 Table V.--Comparison of Total Payments Per Case
                                          [FY 1999 Compared to FY 2000]
----------------------------------------------------------------------------------------------------------------
                                                                                                      Portion
                                     Number of      Average FY      Average FY                     attributable
                                     hospitals    1999 payments/  2000 payments/    All changes     to Federal
                                                       case            case                         rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals...............           4,834             632             645             1.9            -1.4
    Large urban areas                      1,531             731             742             1.5            -1.8
     (populations over 1
     million)...................
    Other urban areas                      1,146             622             636             2.3            -1.3
     (populations of 1 million
     or fewer)..................
    Rural areas.................           2,157             426             438             2.8            -0.4
    Urban hospitals.............           2,677             684             697             1.8            -1.6
        0-99 beds...............             650             501             507             1.1            -1.6
        100-199 beds............             912             602             609             1.2            -1.5
        200-299 beds............             553             660             673             2.0            -1.6
        300-499 beds............             423             704             720             2.3            -1.5
        500 or more beds........             139             892             906             1.5            -1.9
    Rural hospitals.............           2,157             426             438             2.8            -0.4
        0-49 beds...............           1,190             346             359             3.9             0.2
        50-99 beds..............             580             400             413             3.4            -0.1
        100-149 beds............             232             439             451             2.7            -0.4
        150-199 beds............              85             459             479             4.3            -0.4
        200 or more beds........              70             549             550             0.1            -1.1
By Region:
    Urban by Region.............           2,677             684             697             1.8            -1.6
        New England.............             148             693             715             3.1            -1.0
        Middle Atlantic.........             412             751             759             1.1            -2.2
        South Atlantic..........             399             671             692             3.1            -1.0
        East North Central......             444             645             663             2.7            -0.9
        East South Central......             154             642             662             3.1            -1.3
        West North Central......             179             664             672             1.3            -1.8
        West South Central......             331             664             657            -1.1            -2.9
        Mountain................             123             657             667             1.6            -1.2
        Pacific.................             440             762             773             1.5            -1.9
        Puerto Rico.............              47             298             295            -1.0            -1.4

[[Page 24844]]

 
    Rural by Region.............           2,157             426             438             2.8            -0.4
        New England.............              52             507             515             1.6            -0.6
        Middle Atlantic.........              80             446             458             2.7            -1.3
        South Atlantic..........             285             439             451             2.6            -0.4
        East North Central......             300             441             449             1.8            -0.4
        East South Central......             270             391             403             3.2             0.4
        West North Central......             490             417             442             5.9             0.6
        West South Central......             337             380             381             0.3            -1.7
        Mountain................             200             447             466             4.3             0.5
        Pacific.................             138             498             512             2.8            -0.7
By Payment Classification:
    All hospitals...............           4,834             632             645             1.9            -1.4
    Large urban areas                      1,607             724             735             1.5            -1.8
     (populations over 1
     million)...................
    Other urban areas                      1,147             620             635             2.3            -1.3
     (populations of 1 million
     or fewer)..................
    Rural areas.................           2,080             423             435             2.9            -0.4
    Teaching Status:
        Non-teaching............           3,732             532             541             1.7            -1.2
        Fewer than 100 Residents             868             664             679             2.1            -1.6
        100 or more Residents...             234             946             967             2.2            -1.8
        Urban DSH:
            100 or more beds....           1,362             724             737             1.8            -1.6
            Less than 100 beds..              84             505             500            -0.9            -1.2
        Rural DSH:
            Sole Community (SCH/             153             390             418             7.3             0.1
             EACH)..............
            Referral Center (RRC/             55             484             492             1.8            -0.5
             EACH)..............
            Other Rural:
                100 or more beds              57             392             396             1.1            -0.6
                Less than 100                109             331             348             5.3             1.4
                 beds...........
    Urban teaching and DSH:
        Both teaching and DSH...             703             794             811             2.1            -1.7
        Teaching and no DSH.....             337             681             696             2.2            -1.6
        No teaching and DSH.....             743             607             614             1.3            -1.5
        No teaching and no DSH..             971             573             580             1.3            -1.5
    Rural Hospital Types:
        Non special status                   881             378             387             2.6            -0.4
         hospitals..............
        RRC/EACH................             151             490             500             1.9            -0.9
        SCH/EACH................             638             428             446             4.4             0.0
        Medicare-dependent                   352             345             357             3.5             0.0
         hospitals (MDH)........
        SCH, RRC and EACH.......              58             498             511             2.4             0.2
    Hospitals Reclassified by
     the Medicare Geographic
     Classification Review
     Board:
        Reclassification Status
         During FY1999 and
         FY2000:
            Reclassified During              373             553             561             1.3            -1.3
             Both FY1999 and
             FY2000.............
        Reclassified During                  131             594             642             8.1             3.1
         FY2000 Only............
        Reclassified During                  136             531             513            -3.4            -6.3
         FY1999 Only............
    FY2000 Reclassifications:
        All Reclassified                     504             562             578             2.8            -0.3
         Hospitals..............
        All Nonreclassified                4,304             642             654             1.9            -1.5
         Hospitals..............
        All Urban Reclassified                85             751             775             3.2            -1.1
         Hospitals..............
        Urban Nonreclassified              2,592             682             694             1.7            -1.6
         Hospitals..............
        All Reclassified Rural               419             489             502             2.6             0.1
         Hospitals..............
        Rural Nonreclassified              1,712             381             394             3.4            -0.4
         Hospitals..............
    Other Reclassified Hospitals              26             463             429            -7.3            -8.8
     (Section 1886(D)(8)(B))....
    Type of Ownership:
        Voluntary...............           2,826             646             658             1.9            -1.4
        Proprietary.............             721             634             641             1.1            -2.0
        Government..............           1,255             555             572             3.1            -0.8
    Medicare Utilization as a
     Percent of Inpatient Days:
        0-25....................             360             768             789             2.8            -2.1
        25-50...................           1,739             726             737             1.5            -1.7
        50-65...................           1,885             575             588             2.2            -1.2
----------------------------------------------------------------------------------------------------------------


[[Page 24845]]

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 used the capital acquisition model from the start of 
prospective payments for capital costs through FY 1997. We now have 
6 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, 1998 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), PPS-XII (cost reporting 
periods beginning in FY 1995), PPS-XIII (cost reporting periods 
beginning in FY 1996), and PPS-XIV (cost reporting periods beginning 
in FY 1997). In addition, to model payments, we use the January 1, 
1999 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 not paid under the capital 
prospective payment system, we excluded these hospitals from our 
model.
    We developed FY 1992 through FY 1999 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
------------------------------------------------------------------------
Neither File...............................................            1
Audit File only............................................           53
Provider-Specific File Only................................          103
Provider-Specific and Audit File...........................         4717
                                                            ------------
    Total..................................................         4874
------------------------------------------------------------------------

    Sixty-three of the 4,874 hospitals had unusable or missing data, 
or had no cost reports available. For 21 of the 63 hospitals, we 
were unable to determine a hospital-specific rate from the available 
cost reports. However, there was adequate cost information to 
determine that these hospitals were paid under the hold-harmless 
methodology. Since the hospital-specific rate is not used to 
determine payments for hospitals paid under the hold-harmless 
methodology, there was sufficient cost report information available 
to include these 21 hospitals in the analysis. We were able to 
estimate hospital-specific amounts from the PPS-IX cost report data 
for an additional 2 hospitals. Hence, we were able to use 23 of the 
63 hospitals. We used 4,834 hospitals for the analysis. Forty 
hospitals could not be used in the analysis because of insufficient 
information. These hospitals account for less than 0.2 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 old capital has expired. Old capital costs should 
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 first two groups. Each of these groups displayed 
unique patterns of growth in capital costs. We found that the gamma 
distribution is useful in explaining and describing the patterns of 
increase in capital costs. A gamma distribution is a statistical 
distribution that can be used to describe patterns of growth rates, 
with the 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 
1998 (the MedPAR data year) and later, we use the number of 
discharges from the MEDPAR data. Some hospitals have considerably 
more discharges in FY 1998 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

[[Page 24846]]

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 1998 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 1998 MedPAR file using the proposed FY 2000 DRG relative 
weights included in section VI. of the Addendum to this proposed 
rule. The case-mix index is increased each year after FY 1998 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 0.5 percent in FY 1999 and 0.5 percent in FY 2000. 
(Since we are using FY 1998 cases for our analysis, the FY 1998 
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 1999, the budget neutrality adjustment factors 
were 1.00294 for the national rate and 1.00233 for the Puerto Rico 
rate.
    Since we implemented a separate geographic adjustment factor for 
Puerto Rico, we applied separate budget neutrality adjustments for 
the national geographic adjustment factor and the Puerto Rico 
geographic adjustment factor. We applied 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 2000, we first determined the 
portions of the Federal national and Puerto Rico rates that would be 
paid for each hospital in FY 2000 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 1999 DRG relative weights and the FY 
1999 geographic adjustment factor to estimated aggregate Federal 
rate payments based on the FY 1999 relative weights and the FY 2000 
geographic adjustment factor. In making the comparison, we held the 
FY 2000 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 0.99845 for FY 2000 should be 
applied to the previous cumulative FY 1999 adjustment of 1.00294, 
yielding a cumulative adjustment of 1.00139 through FY 2000. For the 
Puerto Rico geographic adjustment factor, an incremental budget 
neutrality adjustment of 1.00151 for FY 2000 should be applied to 
the previous cumulative FY 1999 adjustment of 1.00233, yielding a 
cumulative adjustment of 1.00384 through FY 2000. We apply these new 
adjustments, then compare estimated aggregate Federal rate payments 
based on the FY 1999 DRG relative weights and the FY 2000 geographic 
adjustment factors to estimated aggregate Federal rate payments 
based on the FY 2000 DRG relative weights and the FY 2000 geographic 
adjustment factors. The incremental adjustment for DRG 
classifications and changes in relative weights would be 1.00014 
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 FY 2000 would be 1.00153 
nationally, and 1.00398 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................................  ...........  .................  ...........      1.00000  ...........  .................  ...........  ...........
1993................................  ...........  .................      0.99800      0.99800  ...........  .................  ...........  ...........
1994................................  ...........  .................      1.00531      1.00330  ...........  .................  ...........  ...........
1995................................  ...........  .................      0.99980      1.00310  ...........  .................  ...........  ...........
1996................................  ...........  .................      0.99940      1.00250  ...........  .................  ...........  ...........
1997................................  ...........  .................      0.99873      1.00123  ...........  .................  ...........  ...........
1998................................  ...........  .................      0.99892      1.00015  ...........  .................  ...........      1.00000
1999................................      0.99944         1.00335         1.00279      1.00294      0.99898         1.00335         1.00233      1.00233
2000................................      0.99845         1.00014         0.99859      1.00153      1.00151         1.00014         1.00165      1.00398
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 24847]]

    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 FYs 1992 through 
1999, the proposed factors for FY 2000, and the estimated factors 
that would be applicable through FY 2004. We caution that these are 
estimates for FYs 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 
1.00153 (1.00398 for Puerto Rico) for FY 2000 and later because we 
do not have sufficient information to estimate the change that will 
occur in the factor for years after FY 2000.
    The projections are as follows:

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                               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.........................................................         0.10        .9783          N/A       1.0028        .9392  ...........       378.10
2000.........................................................        -0.60        .9752          N/A        .9986        .9397  ...........       374.31
2001.........................................................         0.50        .9645          N/A     5 1.0000      5 .9397  ...........       372.06
2002.........................................................         0.50     6 1.0000          N/A       1.0000        .9397  ...........       387.68
2003.........................................................         0.50     6 1.0000          N/A       1.0000        .9397     4 1.0255       399.57
2004.........................................................         0.60     6 1.0000          N/A       1.0000        .9397  ...........       401.97
--------------------------------------------------------------------------------------------------------------------------------------------------------
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.

Appendix C: Report to Congress

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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 2000 by hospitals 
subject to the prospective payment system and those excluded from 
the prospective payment system. Section 1886(b)(3)(B)(i)(XV) of the 
Act sets the FY 2000 percentage increase in the operating cost 
standardized amounts equal to the rate of increase in the hospital 
market basket minus 1.8 percent for prospective payment hospitals in 
all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 2000 
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 1.8 percentage points. Under section 1886(b)(3)(B)(ii) 
of the Act, the FY 2000 percentage increase in the rate of increase 
limits for hospitals excluded from the prospective payment system 
ranges from the percentage increase in the excluded hospital market 
basket to 0 percent, depending on the hospital's costs in relation 
to its limit for the most recent cost reporting period for which 
information is available.
    In accordance with section 1886(d)(3)(A) of the Act, we are 
proposing to update the standardized amounts, the hospital-specific 
rates, and the rate-of-increase limits for hospitals excluded from 
the prospective payment system as provided in section 1886(b)(3)(B) 
of the Act. Based on the first quarter 1999 forecast of the FY 2000 
market basket increase of 2.7 percent for hospitals subject to the 
prospective payment system, the proposed updates to the standardized 
amounts are 0.9 percent (that is, the market basket rate of increase 
minus 1.8 percent percentage points) 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 0.9 percent. The proposed update for 
hospitals excluded from the prospective payment system would range 
from 0 percent to the percentage increase in the excluded hospital 
market basket (currently estimated at 2.6 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, 1999 report, MedPAC stated that the legislated 
update of market basket increase minus 1.8 percentage points would 
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 2000. 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 0.0 
percentage points for hospitals located in large urban and other 
areas. We are also recommending an update of 0.0 percentage points 
to the hospital-specific rate for sole community hospitals and 
Medicare-dependent, small rural hospitals. These figures are 
consistent with the President's FY 2000 budget recommendations. 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. This proposed recommendation is based on a more recent 
forecast of the market basket, although still 2.7 percent.
    We recommend that hospitals excluded from the prospective 
payment system receive an update of between 0 and 2.6 percentage 
points. 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, or 0 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 2.6 percent. This recommendation is consistent 
with the President's FY 2000 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 Recommendations for Updating the Prospective Payment System 
Standardized Amounts

    For FY 2000, MedPAC's update framework would support an update 
to the standardized amounts under the prospective payment system 
between the increase in the hospital market basket minus 2.5 
percentage points and the increase in the hospital market basket 
plus 0.1 percentage points. MedPAC notes that hospital total revenue 
margins have continued to increase this decade and the percentage of 
hospitals with negative total revenue margins remains much lower 
than it was a decade ago. Thus, MedPAC believes the statutory update 
of market basket increase minus 1.8 percentage points for FY 2000 is 
reasonable and appropriate.
    MedPAC's estimate of the market basket increase is 2.3 percent, 
based on the fourth quarter 1998 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. When MedPAC published its recommendations, HCFA's 
market basket forecast was 2.5 percent. Thus, MedPAC's update 
framework reflects a 0.2 percent adjustment for this difference.
    Response: Our update recommendation of 0.0 percent is within the 
range of updates MedPAC has suggested for the prospective payment 
system hospitals, albeit at the low end. 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 
through 1989, or 1.2 percent annually. At the same time, ProPAC 
estimated total output growth at 3.4 percent 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

[[Page 24853]]

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, expected quality 
enhancing intensity growth, and 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 (1.0 percent 
for FY 2000), and projected real case-mix growth (0.5 percent), or 
1.5 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 
(1.5 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 0.3 
percent, thus our recommendation includes a -0.3 percent update for 
improved productivity.
    In past years, MedPAC's recommendation has taken into account 
product change. This year, while there is not a specific mention of 
product change in MedPAC's recommendation, similar factors do appear 
in their discussion of ``site of service substitution.'' HCFA takes 
this factor into account when measuring change in intensity, as 
discussed below. In addition, MedPAC's update framework contains a 
productivity adjustment of between -1.0 to 0.0 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 2000, 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'' (pp. 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 FYs 1994 through 1998 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 FYs 1994 through 1998, observed case-mix index change ranged 
from a low of -.04 percent to a high of 1.7 percent, with a 5-year 
average change of 1.0 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, although some years the figures fall outside this 
range. The average percentage change in charge per discharge was 2.9 
percent and the average annual change in the medical CPI was 4.6 
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 -2.9 percent. Assuming the 
technology/fixed cost ratio still holds, technology would account 
for a -1.0 percent annual decline while fixed costs would account 
for a -1.9 percent annual decline. The decline in fixed costs per 
discharge makes intuitive sense as volume, measured by total 
discharges, has 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 2000.
    MedPAC does not make an intensity recommendation per se, but its 
recommendation for the FY 2000 update includes two categories that 
we consider to be comparable with our intensity recommendation. 
MedPAC is recommending a 0.5 to 1.0 update for scientific and 
technological advances to account for increased costs of systems 
conversions necessary for computer compliance on January 1, 2000. 
MedPAC's recommendation also takes into account the increasingly 
apparent trend of some acute care providers to shift care to a 
postacute care facility. While this can occur for many reasons, 
there is good reason to suspect prospective payment system payment 
limits. Accordingly, MedPAC recommends an adjustment of -1.8 to -0.9 
for site-of-care substitution.
    As we mentioned in last year's final rule, higher input prices 
that hospitals incur to convert computer systems to be complaint on 
January 1, 2000, will be accounted for through the market basket. We 
agree with MedPAC that the site of care substitution effect is real 
and believe that it is factored into our intensity recommendation.
    c. 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 2000 update recommendation, we are 
projecting a 0.5 percent increase in the case-mix index. Unlike in 
past years, where we differentiated between ``real'' case-mix 
increase and increases attributable to changes in coding behavior, 
we do not feel changes in coding behavior will impact the overall 
case-mix in FY 2000. As such, we project the entire change will be 
``real.''
    MedPAC also does not expect any case-mix change due to coding 
changes. MedPAC's estimate of overall case-mix change ranges from 
0.0 to 0.2 percentage points for FY 2000.
    d. Effect of FY 1998 DRG Reclassification and Recalibration. We 
estimate that DRG reclassification and recalibration for FY 1998 
resulted in a 0.7 percent decrease 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.
    We make a forecast error correction if the actual market basket 
change for a previous fiscal year differs from the forecasted market 
basket by 0.25 percentage points or more. Our update framework for 
FY 2000 does not reflect a forecast error correction because, for FY 
1998, there was less than a 0.25 percentage point difference between 
the actual market basket and the forecasted market basket.

[[Page 24854]]



                             Table 1.--Comparison of FY 2000 Update Recommendations
----------------------------------------------------------------------------------------------------------------
                                                        HHS                                 MedPAC
----------------------------------------------------------------------------------------------------------------
Market Basket.........................  MB.................................  MB
Difference between HCFA & MedPAC        ...................................  -0.4
 Market Baskets.
                                       -------------------------------------------------------------------------
    Subtotal..........................  MB.................................  MB
Policy Adjustments Factors:
    Productivity......................  -0.3...............................  -1.0 to 0.0
    Site of Service Substitution......  (\3\)..............................  -1.8 to -0.9
    Intensity.........................  0.0................................
        Science & Technology..........  ...................................  0.5 to 1.0
        Practice Patterns.............  ...................................  (\1\)
        Real Within DRG Change........  ...................................  (\2\)
                                       -------------------------------------------------------------------------
            Subtotal..................  -0.3...............................  -2.3 to 0.1
Case-Mix Adjustment Factors:
    Projected Case-Mix Change.........  -0.5...............................
    Real Across DRG Change............  0.5................................  0.0
    Real Within DRG Change............  (\3\)..............................  0.0 to 0.2
                                       -------------------------------------------------------------------------
        Subtotal......................  0.0................................  0.0 to 0.2
Effect of 1998 Reclassification &       -0.7...............................
 Recalibration.
Forecast Error Correction.............  0.0................................  0.0
Total Recommended Update..............  MB -1.0............................  MB -2.7 to MB 0.1
----------------------------------------------------------------------------------------------------------------
\1\ Included in MedPAC's Productivity Measure.
\2\ Included in MedPAC's Case-Mix Adjustment.
\3\ Included in HHS' Intensity Factor.

    While the above analysis would support a recommendation that the 
update be no less than the market basket minus 1.0 percentage 
points, we are recommending an update of 0.0 percentage points. We 
note that had our framework included the negative intensity 
adjustment, the framework would have suggested an update in the 
range of market basket increase minus 3.9 percentage points and 
market basket increase minus 2.0 percentage points. However, 
consistent with past update recommendations, we did not make a 
negative adjustment for intensity this year. A negative intensity 
adjustment would capture the site of care substitution adjustment in 
MedPAC's recommendation. In conjunction with our Office of Actuary, 
we do intend to reexamine our update framework and the 
appropriateness of a negative intensity adjustment.
    For FY 2000, we believe that a 0.0 update factor appropriately 
reflects current trends in health care delivery, including the 
recent decreases in the use of hospital inpatient services and the 
corresponding increase in the use of hospital outpatient and 
postacute care services. Our recommendation is within the range of 
MedPAC's recommendation. We also recommend that the hospital-
specific rates applicable to sole community hospitals be increased 
by the same update, 0.0 percentage points.

IV. MedPAC Recommendation for Updating the Rate-of-Increase Limits for 
Excluded Hospitals and Hospital Units (Recommendation 4A)

    For hospitals and units excluded from the prospective payment 
system, MedPAC's recommendation is that the Secretary ``should 
increase the market basket amount in the target amount update 
formula by 0.4 percentage points for fiscal year 2000.'' For cost 
reporting periods beginning in FY 2000, the statute provides that 
the update to the target amounts for excluded hospitals or units is 
equal to the increase in the excluded hospital operating market 
basket less a percentage between 0 and 2.5 percentage points, or 0 
percent, depending on the hospital's or unit's costs in relation to 
its target amount for the most recent cost reporting period for 
which information is available. MedPAC believes that the update 
formula for excluded hospitals should be adjusted upward by 0.4 
percentage points, to reflect (1) a -0.1 percent adjustment for 
differences between HCFA's and MedPAC's market baskets and (2) a 0.5 
percent adjustment for scientific and technological advances.
    Response: We believe that the statutory update is adequate and 
that an upward adjustment to the statutory formula is unnecessary. 
Thus, we recommend that hospitals excluded from the prospective 
payment system receive an update between 0 percent and the increase 
in the market basket for excluded hospitals. Overall declines in 
inpatient operating costs and high levels of Medicare profit margins 
support our recommendation. 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.

[FR Doc. 99-11200 Filed 5-6-99; 8:45 am]
BILLING CODE 4120-01-P