[Federal Register Volume 64, Number 146 (Friday, July 30, 1999)]
[Rules and Regulations]
[Pages 41490-41641]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-19334]
[[Page 41489]]
_______________________________________________________________________
Part II
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
42 CFR Parts 412, 413, 483, and 485
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 2000 Rates; Final Rule
Federal Register / Vol. 64, No. 146 / Friday, July 30, 1999 / Rules
and Regulations
[[Page 41490]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 412, 413, 483, and 485
[HCFA-1053-F]
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: Final rule.
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SUMMARY: We are revising 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 final rule, we describe
changes in the amounts and factors necessary to determine rates for
Medicare hospital inpatient services for operating costs and capital-
related costs. These changes are applicable to discharges occurring on
or after October 1, 1999. We also set forth rate-of-increase limits as
well as policy changes for hospitals and hospital units excluded from
the prospective payment systems. Finally, we are revising certain
policies governing payment to hospitals for the direct costs of
graduate medical education.
DATES: The provisions of this final rule are effective October 1, 1999.
This rule is a major rule as defined in Title 5, United States Code,
section 804(2). Pursuant to 5 U.S.C. section 801(a)(1)(A), we are
submitting a report to Congress on this rule on July 30, 1999.
FOR FURTHER INFORMATION CONTACT:
Steve Phillips, (410) 786-4531, Operating Prospective Payment,
Diagnosis-Related Group (DRG), and Wage Index Issues.
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded
Hospitals, and Graduate Medical Education Issues.
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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
systems: 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 directly by a
hospital 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 systems 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.
B. Summary of the Provisions of the May 7, 1999 Proposed Rule
On May 7, 1999, we published a proposed rule in the Federal
Register (64 FR 24716) that set forth proposed changes to the Medicare
hospital inpatient prospective payment systems for both operating costs
and capital-related costs that would be effective for discharges
occurring on or after October 1, 1999. We also proposed changes
concerning GME costs and excluded hospitals and units, as well as
critical access hospitals (CAHs). On June 15, 1999, we issued a
correction notice (64 FR 31995) for the May 7, 1999 proposed rule. That
notice corrected Table 3C of the Addendum (which lists each hospital's
case-mix index and adjusted average hourly wage based on data on file
at HCFA as of February 22, 1999) and made several other technical
corrections.
In the proposed rule, we noted that the efforts that we were
undertaking to make the Medicare computer systems compliant on January
1, 2000, would not delay our ability to make timely and updated
payments to hospitals under the FY 2000 prospective payment systems
final rule. This statement still applies and the changes and updated
rates set forth in this final rule will be implemented on October 1,
1999.
The following is a summary of the contents of the proposed rule:
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 did not propose to implement any
revisions to the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) coding system. We did
propose to make some limited changes to certain DRG classifications for
FY 2000 and described other proposed decisions
[[Page 41491]]
concerning DRGs. We also recalibrated the DRG relative weights based on
the proposed DRG changes and updated Medicare claims data.
We proposed an FY 2000 hospital wage index update, using
FY 1996 wage data, and revisions to the wage index based on hospital
redesignations. In addition, we proposed to begin excluding from the
wage index Part A physician wage costs that are teaching-related, as
well as resident and Part A certified registered nurse anesthetist
(CRNA) costs.
We proposed several policy changes in the regulations in
42 CFR parts 412 and 413 and proposed to continue existing policy
concerning classifications of sole community hospitals; the indirect
medical education adjustment; and Medicare Geographic Classification
Review Board (MGCRB) decisions. In addition, we updated the qualifying
criteria for rural referral centers and proposed several changes to the
regulations governing payments for the direct costs of GME programs.
We discussed 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 and proposals that we had
received to change the eligibility criteria for these payments.
We discussed a number of proposals concerning Medicare
payments to excluded hospitals and hospital units and CAHs. These
proposed changes related to 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 Medicare 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;
and compliance with minimum data set requirements by CAHs with swing
bed approval.
In the addendum to the 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 addressed 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.
In Appendix A of the proposed rule, we set forth an
analysis of the impact that the proposed changes would have on affected
entities.
In Appendix B of the proposed rule, we set forth the
technical appendix on the proposed FY 2000 capital cost model.
In Appendix C of the proposed rule, as required by section
1886(e)(3)(B) of the Act, we set forth our 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.
In Appendix D of the proposed rule, as required by
sections 1886(e)(4) and (e)(5) of the Act, we included our
recommendation of the appropriate percentage change for FY 2000 for--
--Large urban area and other area average standardized amounts (and
hospital-specific rates applicable to sole community hospitals and
Medicare-dependent, small rural hospitals) for hospital inpatient
services paid for under the prospective payment system for operating
costs; and
--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.
In the proposed rule, we discussed the recommendations
concerning hospital inpatient payment policies made by the Medicare
Payment Advisory Commission (MedPAC) and presented our responses to
those recommendations. Under section 1805(b) of the Act, MedPAC is
required to submit a report to Congress, not later than March 1 of each
year, that reviews and makes recommendations on Medicare payment
policies.
C. Public Comments Received in Response to the Proposed Rule
We received a total of 82 timely items of correspondence containing
multiple comments on the proposed rule. The main areas of concern
addressed by the commenters were removal of teaching-related and CRNA
costs from the wage index, payments for services furnished at satellite
hospital locations, and limits on the transfer of patients in
hospitals-within-hospitals. We also received a number of comments
relating to the eligibility criteria for hospitals to qualify for
capital exceptions payments.
Summaries of the public comments received and our responses to
those comments are set forth below under the appropriate section.
II. 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 changes to the DRG classification system, and the 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
[[Page 41492]]
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.
We proposed several changes to the DRG classification system for FY
2000 and other decisions concerning DRGs. The proposed changes, the
comments we received concerning them, and the final DRG changes are set
forth below. Unless otherwise noted, our DRG analysis is based on the
full (100 percent) FY 1998 MedPAR file, which contains data from bills
received through March 31, 1999.
2. MDC 15 (Newborns and Other Neonates with Conditions Originating in
the Perinatal Period)
In the May 7, 1999 proposed rule, we noted that the following codes
in the newborn observation series are included in the allowable
secondary diagnoses under DRG 391 (Normal Newborn):
V29.0, Observation for suspected infectious disease
V29.1, Observation for suspected neurological condition
V29.8, Observation for other specified suspected condition
V29.9, Observation for unspecified suspected condition
There are two related codes, however, that currently are not included
as allowable secondary diagnoses under DRG 391: V29.2 (Observation for
suspected respiratory condition) and V29.3 (Observation for suspected
genetic or metabolic condition). (In the proposed rule, we incorrectly
stated that V29.3 was titled ``Observation for other genetic
problem.'') Diagnosis codes V29.2 and V29.3 (as well as the other V29.x
codes noted above) are used to indicate that the newborn was suspected
of having an abnormal condition resulting from exposure from the mother
or the birth process, but is without signs or symptoms and, after
examination and observation, no abnormal condition is found to exist.
Currently, when either V29.2 or V29.3 is the only secondary diagnosis
for an otherwise healthy newborn, the case is assigned to DRG 390
(Neonate with Other Significant Problems). Based on a belief that the
presence of diagnosis code V29.2 or V29.3 should not exclude a newborn
from being classified as normal, we proposed to include diagnosis codes
V29.2 and V29.3 in the list of allowable secondary diagnoses under DRG
391 (Normal Newborn).
We received one comment on this proposal.
Comment: The commenter questioned whether any of the codes in the
V29 series should be assigned to DRG 391. The commenter believes that
the infants assigned to diagnosis code in the V29 series do not belong
in the same clinical group as ``normal newborn.'' The commenter
recommended that, before moving codes V29.2 and V29.3 to DRG 391, we
should examine data such as the average length of stay for DRGs 390 and
391 and those cases coded with V29.x. Citing one hospital's experience,
the commenter noted that 2.7 percent of the cases in DRG 391 were
assigned a secondary diagnosis of V29.0 (Observation for suspected
infectious disease). In addition, cases with secondary diagnosis codes
V29.1, V29.8, and V29.9 represented less than 1 percent each of all
cases in DRG 391. The commenter also reported that, for DRG 390, less
than 1 percent of cases were assigned a secondary diagnosis code of
V29.2 or V29.3. The commenter believes that the length of stay and
resource consumption for these cases should be compared to other cases
assigned to DRG 390 and DRG 391 to determine whether a separate DRG
should be created to adequately categorize these infants.
Response: The experience of the hospital reported by the commenter
indicates that newborn cases with a secondary diagnosis of V29.2 or
V29.3 represent a small percentage of newborn cases. Medicare data do
not contain enough data on newborns to verify this.
In the FY 1998 MedPAR file, there are only nine cases assigned to
DRG 390 and none to DRG 391. In fact, in FY 1998, there were only 18
cases assigned to all of MDC 15. Because of the lack of data on
newborns in the Medicare claims file, the relative weights and lengths
of stay for the DRGs in MDC 15 are based on non-Medicare data collected
from 19 States. (See the September 1, 1995 final rule (60 FR 45781) for
a detailed discussion of this policy.) Therefore, we rely closely on
experts outside of HCFA when we make any changes in MDC 15. We had
received information before publication of the proposed rule suggesting
that V29.2 and V29.3 should be included with the other V29.x codes in
DRG 391. After verifying with our medical consultants that this
information was clinically accurate, we proposed to make this DRG
classification change. We do note that the average lengths of stay for
DRG 390 and 391 do not differ dramatically (3.4 and 3.1 days,
respectively). However, the relative weight for DRG 390 is
significantly higher than that for DRG 391 (1.5908 and 0.1516,
respectively). Thus, we believe the amount of resource use devoted to
newborns in DRG 390 is not
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connected to the amount of time spent in the hospital.
The commenter did not provide any length of stay or resource use
data nor did the commenter provide any reason that codes V29.2 or V29.3
should be treated differently than the other codes in category V29.x.
We believe that DRG 390, as its title indicates, should be used to
classify newborns with significant problems. Newborns who exhibit no
signs or symptoms and are merely evaluated or observed for a suspected
condition that is ruled out should not be classified with newborns who
have significant problems that require treatment.
We note that DRG 391 includes newborns who have minor problems or
conditions that require treatment. For example, some newborns with
jaundice, newborns with scalp injuries or mild birth asphyxia, and
newborns with minor skin infections are all classified to DRG 391.
Thus, that DRG does contain newborn cases for which some medical
treatment must be provided. We believe that including newborns observed
for suspected respiratory, genetic, or metabolic conditions in DRG 391
is clinically appropriate. Therefore, as proposed, we will include
V29.2 and V29.3 as allowable secondary diagnoses under DRG 391, as are
the rest of the codes in that category.
3. MDC 19 (Mental Diseases and Disorders)
We proposed to revise the title of DRG 425, ``Acute Adjustment
Reaction and Disturbances of Psychosocial Dysfunction'' under MDC 19 to
read ``Acute Adjustment Reaction and Psychosocial Dysfunction.''
Correspondents had stated that the terms ``disturbances'' and
``dysfunction'' were redundant since the terms have similar meanings.
We received one comment in support of this revision. Therefore, we
are adopting this proposed revision as final.
4. MDC 22 (Burns)
In the July 31, 1998 final rule (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. After these DRGs went into effect on October 1, 1998, we were
contacted by several hospitals about our inclusion of the fifth digit
``0'' on codes 948.10 through 948.90 to capture cases of full-thickness
burns. These hospitals stated that 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 full-thickness
(third degree) burn. The fifth digit ``0'' 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'' as follows:
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.
We agreed with the hospitals and proposed that the codes listed
above be removed from DRGs 506 through 509 and added to DRG 510
(Nonextensive Burns with CC or Significant Trauma) and DRG 511
(Nonextensive Burns without CC or Significant Trauma). 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 (codes 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 would 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 in which 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 would continue to be classified as full-thickness burns in
DRGs 506 through 509. Therefore, the proposed removal of codes 948.1
through 948.9 with a fifth digit of ``0'' would 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.
Comment: One commenter stated that while it is true that codes in
category 948 with a fifth digit of ``0'' may be assigned when there is
no third degree burn, fifth digit ``0'' is also used to report cases
that have a body surface of 1 to 9 percent involved in third degree
burns. The commenter suggested that consideration be given to these
cases as the presence of a third degree burn represents additional risk
to the patient.
Response: We agree with the commenter that the presence of third
degree burns represents additional risk to the patient and may result
in a higher resource use. More accurately capturing this fact was one
of the primary purposes in revising the burn DRGs in FY 1999. However,
as the commenter noted, in category 948, the fifth digit of ``0''
includes cases with no third degree burns as well as third degree burns
involving 1 to 9 percent of the body surface. It is precisely because
many of the cases coded in 948 with a ``0'' fifth digit have no third
degree burns that we believe it is not appropriate to include these
codes in DRGs 506 through 509. As stated above, hospitals have been
instructed to code the site of the burn first (codes 940 through 947),
when known. These codes capture information on the site of the burn as
well as whether the burn is a third degree burn. Therefore, by using
the more precise codes in the 940 through 947 series, hospitals will be
appropriately assigning cases with minor third degree burns to DRGs 506
through 509.
We are adopting as final our proposal to remove codes in the 948
category with a fifth digit of ``0'' from the list of full-thickness
burns.
5. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in
[[Page 41494]]
assignment of the case to a different DRG within the MDC to which the
principal diagnosis is assigned. It is, therefore, necessary to have a
decision rule by which these cases are assigned to a single DRG. The
surgical hierarchy, an ordering of surgical classes from most to least
resource intensive, performs that function. Its application ensures
that cases involving multiple surgical procedures are assigned to the
DRG associated with the most resource-intensive surgical class.
Because the relative resource intensity of surgical classes can
shift as a function of DRG reclassification and recalibration, we
reviewed the surgical hierarchy of each MDC, as we have for previous
reclassifications, to determine if the ordering of classes coincided
with the intensity of resource utilization, as measured by the same
billing data used to compute the DRG relative weights.
A surgical class can be composed of one or more DRGs. For example,
in MDC 5, the surgical class ``heart transplant'' consists of a single
DRG (DRG 103), and the class ``major cardiovascular procedures''
consists of two DRGs (DRGs 110 and 111). Consequently, in many cases,
the surgical hierarchy has an impact on more than one DRG. The
methodology for determining the most resource-intensive surgical class
involves weighting each DRG for frequency to determine the average
resources for each surgical class. For example, assume surgical class A
includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5.
Assume also that the average charge of DRG 1 is higher than that of DRG
3, but the average charges of DRGs 4 and 5 are higher than the average
charge of DRG 2. To determine whether surgical class A should be higher
or lower than surgical class B in the surgical hierarchy, we would
weight the average charge of each DRG by frequency (that is, by the
number of cases in the DRG) to determine average resource consumption
for the surgical class. The surgical classes would then be ordered from
the class with the highest average resource utilization to that with
the lowest, with the exception of ``other OR procedures'' as discussed
below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average relative
weight is ordered above a surgical class with a higher average relative
weight. For example, the ``other OR procedures'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weight for the DRG
or DRGs in that surgical class may be higher than that for other
surgical classes in the MDC. The ``other OR procedures'' class is a
group of procedures that are least likely to be related to the
diagnoses in the MDC but are occasionally performed on patients with
these diagnoses. Therefore, these procedures should be considered only
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 proposed to
modify the surgical hierarchy as set forth below. However, in
developing the proposed rule, we were 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 was prepared.
Rather, we simulated most major classification changes to approximate
the placement of cases under the proposed reclassification and then
determined the average charge for each DRG. These average charges then
serve as our best estimate of relative resource use for each surgical
class. We tested the proposed surgical hierarchy changes after the
revised GROUPER was received. The final changes in the DRG relative
weights are reflected in this final rule.
We proposed 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 proposed to reorder Lung
Transplant (DRG 495) above Bone Marrow Transplant (DRG 481).
In MDC 3, we proposed to reorder Tonsil and Adenoid
Procedure Except Tonsillectomy and/or Adenoidectomy Only (DRGs 57 and
58) above Cleft Lip and Palate Repair (DRG 52).
We received two comments in support of the two surgical hierarchy
proposals. In addition, based on a test of the proposed revisions using
the most recent MedPAR file and the revised GROUPER software, we have
found that the revisions are still supported by the data and no
additional changes are indicated. Therefore, we are incorporating the
proposed revisions and reorders in this final rule.
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
by deleting CCs already on the list. In the May 7, 1999 proposed rule,
we did 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.
[[Page 41495]]
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).) In the May 7, 1999
proposed rule, we did not propose to add or delete any codes from the
CC list.
In addition, because we are not making changes to the ICD-9-CM
codes for FY 2000, we are not modifying the current list for new or
deleted codes. Therefore, there are no 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
that do not occur with sufficient frequency to represent a distinct,
recognizable clinical group. DRG 476 is assigned to those discharges in
which one or more of the following prostatic procedures are performed
and are unrelated to the principal diagnosis:
60.0 Incision of prostate
60.12 Open biopsy of prostate
60.15 Biopsy of periprostatic tissue
60.18 Other diagnostic procedures on prostate and periprostatic tissue
60.21 Transurethral prostatectomy
60.29 Other transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostatic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with
DRG 477 assigned to those discharges in which the only procedures
performed are nonextensive procedures that are unrelated to the
principal diagnosis. The original list of the ICD-9-CM procedure codes
for the procedures we consider nonextensive procedures, if performed
with an unrelated principal diagnosis, was published in Table 6C in
section IV of the Addendum to the September 30, 1988 final rule (53 FR
38591). As part of the final rules published on September 4, 1990,
August 30, 1991, September 1, 1992, September 1, 1993, September 1,
1994, September 1, 1995, August 30, 1996, and August 29, 1997, we moved
several other procedures from DRG 468 to 477, 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 proposed to move to surgical
DRGs for additional MDCs so that they are not assigned to DRG 468. We
did not identify any necessary changes in procedures under DRG 477 and,
therefore, did not propose to move any procedures from DRG 477 to one
of the surgical DRGs.
First, we proposed 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. Our medical advisors believe that procedure code
38.7 is appropriately performed for some neurological conditions such
as a cerebral embolism with infarction. Because the current DRG
configuration does not allow this assignment, we proposed to add
procedure code 38.7 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 proposed 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 is performed for
patients who develop pulmonary embolism. The principal diagnosis for
pulmonary embolism is in MDC 4, and, to increase clinical coherence, we
proposed 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
[[Page 41496]]
be assigned to all MDCs in which 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
proposed to add procedure code 86.06 to DRG 120 (Other Circulatory
System OR Procedures) in MDC 5.
We received two comments on these MDC and DRG assignments, both of
which concurred with our proposed changes. Therefore, we are adopting
them as final.
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 did not propose 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
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 4 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 FE 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 4 and November 2, 1998,
that (if approved) ordinarily would have been included as new codes for
October 1, 1999, are not included in this final rule. These code
changes to ICD-9-CM will be considered for inclusion in the annual
update for FY 2001. The initial meeting for consideration of coding
changes for implementation in FY 2001 was held on May 13, 1999.
Copies of the minutes of the 1998 meetings and the May 13, 1999
meeting can be obtained from the HCFA Home Page at http://www.hcfa.gov/
medicare/icd9cm.htm or from http://www.hcfa.gov/events, click on
``meetings and workshops'' link, and then click on ``reports of the
ICD-9-CM coordination and maintenance committee'' link. 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].
We received one comment in support of our decision not to update
ICD-9-CM codes given the magnitude of system changes needed during the
period leading up to the year 2000.
9. Other Issues
a. 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, in the May 7,
1999 proposed rule, we proposed 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
[[Page 41497]]
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 proposed to
add procedure codes 82.56 and 83.92 to DRGs 7 and 8. We did not receive
any comments on this proposal. Therefore, we are adopting it as final.
b. Pancreas Transplant
Through a Medicare Coverage Issues Manual revision (Transmittal No.
115, April 1999), HCFA announced that, effective July 1, 1999, Medicare
covers whole organ pancreas transplantation (procedure codes 52.80 or
52.83) if it is performed simultaneous with or after a kidney
transplant.
Pancreas transplantation is generally limited to those patients
with severe secondary complications of diabetes, including kidney
failure. However, pancreas transplantation is sometimes performed on
patients with labile diabetes and hypoglycemic unawareness.
Pancreas transplantation for diabetic patients who have not
experienced end-stage renal failure secondary to diabetes continue to
be excluded from coverage. Medicare also excludes coverage of
transplantation of partial pancreatic tissue or islet cells. Claims
processing instructions to intermediaries were contained in Program
Memorandum Transmittal No. A-99-16 (April 1999).
We received one comment regarding the coverage and claims
processing instructions for pancreas transplants.
Comment: The commenter requested clarification on the date of
coverage for services related to pancreas transplantation services
furnished on or after July 1, 1999. Specifically, the commenter asked
whether coverage is effective for admissions, discharges, or actual
transplant surgery on or after that date. In addition, the commenter
believes that if the resource use for a pancreas-kidney transplant is
significantly greater than for a kidney transplant alone, then a new
DRG should be created for the dual transplant. Finally, the commenter
was unsure how hospitals should report the organ acquisition costs
attributable to pancreas. Specifically, the commenter wanted to know if
the costs should be included, on the hospital cost report with the
kidney costs or whether a separate organ acquisition cost center will
be established for pancreas acquisition costs.
Response: As stated in Transmittal No. 115, coverage is effective
for dates of service on or after July 1, 1999. Therefore, any pancreas
transplant performed on or after July 1, 1999 is covered by Medicare if
all other qualifying criteria are met.
Under the current DRG classification, if a kidney transplant and a
pancreas transplant are performed simultaneously on a patient with
chronic renal failure secondary to diabetes with renal manifestations
(diagnosis codes 250.40 through 250.43), the case is assigned to DRG
302 (Kidney Transplant) in MDC 11 (Disease and Disorders of the Kidney
and Urinary Tract. If a pancreas transplant is performed following a
kidney transplant (that is, in a different hospital admission) on a
patient with chronic renal failure secondary to diabetes with renal
manifestations, the case is assigned to DRG 468 (Major OR Procedure
Unrelated to Principal Diagnosis) because pancreas transplant is not
assigned to MDC 11, the MDC to which a principal diagnosis of chronic
renal failure secondary to diabetes is assigned.
If a kidney and pancreas transplant are performed simultaneously or
if a pancreas transplant is performed following a kidney transplant, on
a patient with chronic renal failure secondary to diabetes with
ketoacidosis (diagnosis codes 250.10 through 250.13), diabetes with
hyperosmolarity (diagnosis codes 250.20 through 250.23), diabetes with
other coma (diagnosis codes 250.30 through 250.33), diabetes with other
specified manifestations (diagnosis codes 250.80 through 250.83), or
diabetes with unspecified complication (diagnosis codes 250.90 through
250.93), the case would be assigned to DRG 292 or 293 (Other Endocrine,
Nutritional and Metabolic OR Procedures) in MDC 10 (Endocrine,
Nutritional, and Metabolic Diseases and Disorders). As the commenter
notes, it is possible that the resource use for a pancreas-kidney
transplant or a pancreas-only transplant might be significantly
different from a kidney-only transplant. We intend to review the
Medicare data in our FY 1999 MedPAR file in order to analyze whether we
should either reassign these transplants to a different DRG or create a
new DRG. We will announce any proposals on that issue in the FY 2001
proposed rule, which will be published in the Spring of 2000.
A separate organ acquisition cost center has been established for
pancreas transplantation. The Medicare cost report will include a
separate line to account for pancreas transplantation costs. In
addition, in this final rule, we are making a conforming change to '
412.2(e)(4) to include pancreas in the list of organ acquisition costs
that are paid on a reasonable cost basis.
c. Immunotherapy
Effective October 1, 1994, procedure code 99.28 (Injection or
infusion of biological response modifier [BRM] as an antineoplastic
agent) was created. This procedure is also known as BRM therapy or
immunotherapy. At that time, we designated the code as a Anon-OR@ code
that does not affect DRG assignment.
Comment: One commenter, a manufacturer of a biologic response
modifier, requested that we create a new DRG for BRM therapy or assign
cases in which BRM therapy is performed to an existing DRG with a high
relative weight. The commenter suggested that DRG 403 (Lymphoma and
Non-Acute Leukemia with CC) would be an appropriate DRG. The
manufacturer=s particular drug is used in the treatment of metastatic
renal cell carcinoma and metastatic melanoma.
Response: Using the 100 percent FY 1998 MedPAR file that contains
bills through December 31, 1998, we performed an analysis of the cases
for which procedure code 99.28 was reported. Based on the commenter's
request, for purposes of this analysis we examined cases only for
hospitals that use the particular drug manufactured by the commenter.
We identified 121 cases in 19 DRGs in 9 MDCs. No more than 31 cases
were assigned to any one particular DRG. Of the 121 cases identified,
31 cases were assigned to DRG 318 (Kidney and Urinary Tract Neoplasms
with CC) and 30 of the cases were assigned to DRG 82 (Respiratory
Neoplasms). There was a wide range of charges (between approximately
$1,300 and $125,000 per case) associated with this therapy. The average
length of stay was approximately 5 days. Due to the limited number of
cases that were
[[Page 41498]]
distributed throughout 19 DRGs and the variation of charges, we
concluded that it would be inappropriate to classify these cases into a
single DRG. Because of the numerous principal diagnoses reported with
BRM therapy, a single DRG for procedure code 99.28 would need to be
placed in the pre-MDC DRG category. Similarly, it would be impossible
to classify these cases into DRG 403 because only a few cases were
coded with a principal diagnosis assigned to MDC 17 (Myeloproliferative
Diseases and Disorders, and Poorly Differentiated Neoplasms), the MDC
that includes DRG 403. Finally, the variation in charges reflected in
the 121 cases do not persuade us that there is an analytic basis for
combining these cases into one DRG. Using the FY 1999 MedPAR, we intend
to do a full analysis of these cases, which we will discuss in the FY
2001 proposed rule.
As a final note, any DRG classification change for procedure code
99.28 must be appropriate for all cases that receive BRM therapy, not
just those that use the commenter's drug. Even if we might consider
such an assignment appropriate, we have no way to distinguish between
different drug therapies assigned to the same procedure code. The FY
1998 MedPAR file we analyzed contained 930 cases with procedure code
99.28. These 930 cases were assigned to 18 MDCs.
d. Heart Assist Devices
Effective May 5, 1997, we revised Medicare coverage of heart assist
devices to allow coverage of a ventricular assist device used for
support of blood circulation postcardiotomy if certain conditions were
met. In the August 29, 1997 final rule (62 FR 45973), we moved
procedure code 37.66 (Implant of an implantable pulsatile heart assist
device) from DRGs 110 and 111 (Major Cardiovascular Procedures) to DRG
108 (Other Cardiothoracic Procedures) to improve payment for these
procedures. In the July 31, 1998 final rule (63 FR 40956), in a further
effort to improve payment for these cases, we moved procedure code
37.66 to DRGs 104 and 105 (Cardiac Valve and Other Major Cardiothoracic
Procedures).
We received one comment regarding the DRG classification of
procedure code 37.66.
Comment: The commenter recommended that we either reclassify heart
assist device cases to DRG 103 (Heart Transplant) or create a new DRG
specifically for this device and technology. The commenter cited a
discrepancy between the cost of the device implantation and payment for
DRGs 104 and 105 as the basis for these recommendations.
Response: We refer the reader to our response to a similar comment
in the August 29, 1997 final rule (62 FR 45967). We note that the FY
1998 MedPAR file has 22 cases coded with procedure code 37.66. Of these
22 cases, 8 cases were assigned to DRG 103 (Heart Transplant) and 4
cases to DRG 483 (Tracheostomy Except for Face, Mouth, and Neck
Diagnoses). The remaining 10 cases would have been assigned to DRGs 104
and 105 under the current classification.
C. Recalibration of DRG Weights
We proposed 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 recalibrated the weights based on charge
data for Medicare discharges. However, we used 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 final recalibrated DRG relative weights are constructed from FY
1998 MedPAR data, based on bills received by HCFA through March 1999,
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 11.3 million Medicare discharges.
The methodology used to calculate the DRG relative weights from the
FY 1998 MedPAR file is as follows:
All the claims were regrouped using the DRG classification
revisions discussed above in section II.B of this preamble.
Charges were standardized to remove the effects of
differences in area wage levels, indirect medical education (IME) and
disproportionate share hospital (DSH) 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 were used in computing the current weights--that is, all
cases that are outside of 3.0 standard deviations from the mean of the
log distribution of both the charges per case and the charges per day
for each DRG.
The average charge for each DRG was then recomputed
(excluding the statistical outliers) and divided by the national
average standardized charge per case to determine the relative weight.
A transfer case is counted as a fraction of a case based on the ratio
of its length of stay to the geometric mean length of stay of the cases
assigned to the DRG. That is, a 5-day length of stay transfer case
assigned to a DRG with a geometric mean length of stay of 10 days is
counted as 0.5 of a total case.
We established the relative weight for heart and heart-
lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner
consistent with the methodology for all other DRGs except that the
transplant cases that were used to establish the weights were limited
to those Medicare-approved heart, heart-lung, liver, and lung
transplant centers that have cases in the FY 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 used that same case threshold in
recalibrating the DRG weights for FY 2000. Using the FY 1998 MedPAR
data set, there are 40 DRGs that contain fewer than 10 cases. We
computed the weights for the 40 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 final DRG classification changes, result in an average case
weight that is different from the average case weight
[[Page 41499]]
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 ensures 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 final rule, we make a budget
neutrality adjustment to ensure 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 final rule, we used the MedPAR file, which
consists of data for approximately 11.3 million Medicare discharges. In
the FY 1999 final rulemaking process, we used the FY 1997 MedPAR file
to recalibrate DRGs and evaluate possible changes to DRG
classifications; for this FY 2000 final 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 in the
rulemaking process for FY 1999 and in developing the May 7, 1999
proposed rule for FY 2000. We received non-MedPAR data from entities on
behalf of the manufacturer of a specific drug, platelet inhibitors. The
manufacturer was 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 in the proposed rule,
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 were 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 for
rejecting the non-MedPAR data we had received. Basically, the data were
unreliable and the data's use was not feasible--the data could not be
validated or verified.
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 the hospital that furnished the services. Before
the publication of the proposed rule, we had not received information
necessary to validate the data or the data's 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
reflected the major factors that we consider in evaluating whether data
are feasible, reliable, and validated; however, because we believed it
might be useful, we discussed these issues in much greater detail in
the May 7, 1999 proposed rule.
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 above, 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
independently validated. When an entity submits non-MedPAR data, we
[[Page 41500]]
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
resources 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. Prior to the publication of the proposed rule, the same drug
manufacturer discussed above 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.
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 the data's 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 to
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, that is, additional
payments over and above the standard prospective payment rate.
Second, Medicare promotes access to new technologies by making
payments under the prospective 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 prospective 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. We still remain open to using
non-MedPAR data if the data are reliable and validated and enable us to
appropriately measure relative resource use.
We received a number of comments regarding this issue, including
comments from MedPAC, pharmaceutical manufacturers (including two
manufacturers of platelet inhibitor drugs), an industry manufacturers'
association, and several
[[Page 41501]]
cardiologists. We received only one comment from a State hospital
association; otherwise, hospital associations were silent on this
issue.
Comment: MedPAC stated that HCFA's general criteria provide a valid
basis for assessing the feasibility and appropriateness of using
outside data to establish DRG assignments and relative weights for
specific technologies. MedPAC believes that it would be helpful to
entities that desire to submit useful data if HCFA would establish and
publish explicit data standards to guide their efforts. MedPAC
suggested the criteria might include the format and content of the
patient care records; the minimum sample size; required documentation
of sampling procedures; acceptable methods for ensuring that the
sampled providers were representative of the relevant provider
universe; and any other information that HCFA considered essential to
establish the validity and reliability of the submitted data. MedPAC
believes that the criteria would help to prevent misunderstandings and
ensure HCFA's ability to assess whether the submitted data were
adequate to serve as a basis for DRG assignment before actual MedPAR
claims become available.
Response: We appreciate the Commission's support of our general
criteria. We would prefer to gain further experience working with non-
MedPAR data before we develop any specific criteria regarding sample
sizes or methodologies. This will enable us to establish criteria that
realistically reflect the availability of such data and the general
suitability of the data for use in the DRG reclassification and
recalibration process. Our intent at this time is to address some
fundamental criteria that must be taken into consideration by outside
parties interested in submitting non-MedPAR data.
We note that the timetable we set forth in the proposed rule is
intended to provide adequate opportunity to permit outside parties to
conform their data to our needs through testing and resubmission. This
is the primary reason we believe it is generally necessary to have a
sample of the data 8 months prior to the publication of the proposed
rule. We are willing to meet with outside parties interested in
submitting non-MedPAR data for consideration, and would suggest that
those interested in submitting such data in the future should contact
us to discuss the specific data they wish to submit and whether the
data may be adequate.
Comment: One commenter, while supporting the idea that the data
must be reliable and verifiable, indicated that HCFA should consider
other means by which to accomplish this purpose. The commenter stated
that many of the sources for data are restricted from releasing
identifying elements of the data they collect. The commenter claimed,
for example, that they could validate the method by which the data were
assembled, thereby alleviating our concern that the cases may not
represent Medicare beneficiaries or that the reported charges are
inaccurate.
Response: We are open to considering any feasible method for
validating non-MedPAR data, and that is why at this time we are not
specifying explicit criteria for the types of data we will or will not
consider. Instead, we have outlined general guidelines and fundamental
objectives that must be met. One of those fundamental objectives is
that we must be able to validate the data and to accurately identify
cases to be reclassified during DRG recalibration.
In order to preserve the integrity of the DRG reclassification and
recalibration process, we generally believe it is imperative that we
are able to independently validate the data submitted. As noted
previously, 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 that data. In addition, it is not enough to
simply decide that a particular diagnosis or procedure code should now
be classified to a higher-weighted DRG. Cases in the MedPAR data used
for recalibration with that diagnosis or procedure code should be
reclassified accordingly. Otherwise, these cases will affect the
calculation of the relative weights of other DRGs. Therefore, in order
to allow us to ensure the accuracy of DRG recalibration, we must have
some mechanism for ensuring that DRG weights are not inappropriately
inflated.
Comment: Some commenters stated that the criteria regarding the
feasibility of using the data are inconsistent with the intent of the
Conference Report language. The commenters contend that there is no
need to identify each case involving a new technology. Rather, the
agency can extrapolate the findings from a representative sample of
cases and estimate which cases must be moved from one DRG to another.
Two of the commenters stated that this approach was used in
reclassifying lithotripsy to an appropriate DRG, and that extrapolation
is used to some degree in setting the physician fee schedule and was
used in the proposed outpatient prospective payment system. One
commenter wanted us to clarify that we would accept a representative,
statistically valid sample of both non-HCFA and HCFA data that reflect
cases for a period of less than a full year, as well as requesting that
we specify the sources (for example, private payers, manufacturers of
medical technologies, or suppliers) from which we are willing to accept
such data.
Response: We did not rule out the use of extrapolation based on
non-MedPAR data in the proposed rule. In fact, we stated that the data
must reflect either a complete set of cases, or, at a minimum, a
representative sample of hospitals and claims. However, as stated
previously, the process of recalibrating the DRG weights requires that
cases be moved consistent with the reclassification of diagnosis or
procedure codes from one DRG to another. Failure to do so could lead to
inflated or deflated relative weights, which, in turn, result in over
or underpayments for cases in the affected DRGs.
We are attempting to accommodate the realities faced by outside
parties as they attempt to collect and present non-MedPAR data for
consideration. In addition, we will continue to explore our processes
for ways to incorporate such data while preserving the empirical and
clinical integrity of the recalibration process.
As noted by two commenters, in the September 3, 1986 final rule (51
FR 31486), we did, based on analysis by the Prospective Payment
Assessment Commission (ProPAC), assign all cases involving a principal
diagnosis of urinary stones treated by extracorporeal shock wave
lithotripsy (ESWL) to DRG 323 (Urinary stones, age >69 and/or CC).
Prior to this DRG change, ESWL cases were assigned to either DRG 323 or
DRG 324, depending on the presence of a CC or based on the patients age
(over 69). The Commission, an independent advisory body established by
Congress (and MedPAC's predecessor organization), obtained information
on ESWL procedure costs and other routine and ancillary hospital
service charges from the American Heart Association (AHA), the American
Urological Association, and seven hospitals that furnished ESWL. In
addition, ProPAC obtained a preliminary summary of a study conducted by
the Institute for Health Policy Analysis at Georgetown University
Medical Center. This study included cost data from 16 hospitals that
furnished lithotripsy. At the time of these studies, approximately 50
hospitals were furnishing ESWL. Because the ProPAC data were obtained
directly from hospitals and were verified by the Commission at the
[[Page 41502]]
hospital level, we believed the data were reliable and used the data as
a basis for reassigning ESWL cases to DRG 343 only. A full explanation
of the study and ProPAC's analysis and recommendations can be found in
the Technical Appendixes that accompanied ProPAC's April 1, 1986 Report
to Congress.
We have not precluded using either external or internal data that
represent less than a full year's worth of cases. For example, we could
examine a partial year's worth of cases from the current Federal fiscal
year rather than the preceding year's complete MedPAR. Once again,
however, a feasible approach must be developed to enable the
appropriate classification and recalibration of the DRG weights.
Finally, we do not believe it is necessary, or appropriate, to
identify in advance the sources from which we are willing to accept
data. At this time, we remain open to considering any data source that
is reliable, verifiable, and feasible. We would note, however, that
involving hospitals in any data collection would probably aid HCFA in
any validation effort. Generally, if we receive non-MedPAR data, we
will be contacting the hospitals that furnished the sources to verify
some or all of the data.
Comment: Two commenters stated the timeframe for submission of the
non-MedPAR data is unreasonable. They suggested that the submission of
data 7 months before the updated DRGs take effect (March 1) in the case
of internal HCFA data, and 8 months (February 1) in the case of
external data, would more appropriately ensure beneficiary access.
Response: The length of time necessary to validate non-MedPAR data
depends on the nature and quality of the data. In the proposed rule, we
stated that 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 verify and test the data and make a
preliminary assessment as to the feasibility of the data's use.
Subsequently, a complete database should be submitted no later than
December 1, approximately 4 months prior to the publication of the
proposed rule.
We do not believe that this timeframe is unreasonable. If we were
to adopt the commenter's suggestion, we would receive non-MedPAR data
only 2 months before the proposed rule is scheduled to be published
(April 1). This might not allow us sufficient time to ensure that the
data are reliable or valid prior to their use in preparing the proposed
rule.
We believe the timeframe we set forth is necessary to enable us to
independently validate any non-MedPAR data submitted. In order to
verify the data's reliability and validity, we believe we need to
review a sufficient number of the medical records associated with the
data. Expecting us to be able to accomplish this in a matter of weeks
after receiving the data (which is all the time that would be available
for data received in February due to the requirement to begin the
process of reclassifying and recalibrating the proposed DRGs by the end
of February in order for the proposed rule to be published by April 1)
is unrealistic.
Comment: Many of the commenters, including the manufacturer of the
platelet inhibitor drug, national associations representing device and
drug manufacturers, and individual cardiologists, argued that our
current process has inhibited the development of new medical
technologies, and that the criteria for the use of non-MedPAR data are
unworkable and would further slow the development of new technologies.
Several commenters asserted that certain new technologies (including
platelet inhibitors) are denied to Medicare beneficiaries due to
insufficient payment.
Response: After 15 years of administering the prospective payment
system, we do not have any independent evidence that Medicare
beneficiaries are being denied access to new technologies by hospitals
or physicians. Although we have always acknowledged that there is a
time-lag between the time new technologies are introduced and the point
at which we can begin to accurately identify their associated costs, we
believe this has not hampered Medicare beneficiaries' access to these
new technologies. The fact that under the prospective payment system a
hospital might lose money on some cases but will gain money on other
cases is well understood by hospitals. We received no comments from
hospitals or beneficiary advocates complaining about access to new
technologies in general or drug therapies in particular, and only a
brief comment from a State hospital association that indicated that the
use of non-MedPAR data should extend beyond drug therapies.
Furthermore, as provided in Sec. 489.53(a)(2), HCFA may terminate its
participation agreement with any hospital if HCFA finds that the
hospital places restrictions on the persons it will accept for
treatment and it fails either to exempt Medicare beneficiaries from
those restrictions or to apply them to Medicare beneficiaries the same
as to all people seeking care.
Comment: Several commenters, including the manufacturer of a
platelet inhibitor drug and individual cardiologists, specifically
commented on our discussion in the proposed rule of the attempts by the
manufacturer of the drug to introduce its data into the process, with
the objective that cases in which platelet inhibitor therapy is
administered should be reclassified from DRG 112 (Permanent
Cardiovascular Procedures) to DRG 116 (Other Permanent Cardiac
Pacemaker Implant or PTCA with Coronary Artery Stent Implant) for FY
2000. The commenters stated that HCFA has been unwilling to consider
the data. One commenter stated that HCFA refused to accept these data
when they were offered in December 1998.
Response: As discussed in great detail above, and also in the FY
1999 final rule, our review of the previous data submitted by the drug
manufacturer found the data to be insufficient. Despite our
consultation with the manufacturer's representatives in advance of
their submission of data during the rulemaking process for FY 1999
(that is during the first half of calendar year 1998), in which we
advised them that we must be able to identify individual hospitals and
patients in order to utilize the data, this information was not
included on over 90 percent of the cases submitted in May 1998. As
noted in the May 7, 1999 proposed rule, we continued to meet and
correspond with the manufacturers, contractors, and legal
representatives of the pharmaceutical company in an effort to resolve
data issues. At no time have we refused to consider any data offered by
the company or its agents.
However, our discussions with these parties led us to the
conclusion that it might be helpful to identify general criteria for
submission of non-MedPAR data in the proposed rule. In particular, we
were concerned that outside parties wishing to submit non-MedPAR data
were unfamiliar with our current process and the importance of
accurately reclassifying and recalibrating the DRGs. The DRG relative
weights are the principle factor in adjusting the prospective payments
for each of approximately 11 million Medicare discharges each year. In
addition to the potential financial implications to the Medicare Trust
Fund and to hospitals themselves if these weights are inaccurate,
inappropriately assigning cases to higher-weighted DRGs may create
incentives that are not in the best interest of Medicare beneficiaries.
We are hopeful that, by explaining the general criteria for
submitting non-
[[Page 41503]]
MedPAR data and receiving public comments on those criteria, we can
help to ensure that in the future those interested in submitting non-
MedPAR data will be better informed regarding how the process can work.
In particular, we believe the timeframe we set will enable us to work
effectively with those interested in submitting non-MedPAR data to help
them provide data that can be used.
Comment: A manufacturer of a platelet inhibitor drug expressed
concern that HCFA may assign a special DRG classification for patients
who receive coronary intervention with an angioplasty and treatment
with platelet inhibitor therapy, but not for acute coronary syndrome
patients who receive the same drugs without coronary intervention.
These latter cases are assigned to DRG 124 (Circulatory Disorders
Except Acute Myocardial Infarction, with Cardiac Catheterization and
Complex Diagnoses) or DRG 140 (Angina Pectoris). The commenter stated
that if we were to modify payment for one use and not the other, it
would potentially create a financial incentive for expensive, risky,
and invasive treatment. Making payment provisions for both indications
at the same time, on the other hand, will give neither use an advantage
over the other. We were asked by the commenter to evaluate platelet
inhibitor therapy cases assigned to DRG 124 or DRG 140.
Response: Because this is the first comment we have received
regarding the noncoronary intervention use of the therapy, an extensive
study of DRGs 124 and 140 before publication of this final rule was not
feasible. We will evaluate this issue as part of our annual update for
FY 2001, when we will have MedPAR data capturing injection or infusion
of platelet inhibitor (ICD-9-CM procedure code 99.20). This commenter's
concern that increasing payment for one application of platelet
inhibitors but not for others could actually create an inappropriate
incentive in favor of a more invasive treatment, illustrates the
importance of proceeding cautiously in the process of DRG
reclassification and recalibration. We have a responsibility not to
inadvertently create financial incentives that adversely affect
clinical decisionmaking.
Comment: During the comment period, we received a revised set of
data from the manufacturer seeking to have platelet inhibitor therapy
cases receiving angioplasty reclassified from DRG 112 to DRG 116. The
data contain 27,673 cases from 164 hospitals in which Medicare patients
underwent an angioplasty. The commenter describes the data as Athe
public MedPAR file with an additional field that identifies the MedPAR
case as involving an angioplasty with or without platelet inhibitor
therapy. Thus, HCFA can identify the patient and the hospital from
these data such that they are reliable and verifiable. It also is a
representative sample of claims and, therefore, it is feasible for the
agency (HCFA) to use the data set. In light of the significant number
of angioplasty cases contained in the data, HCFA should be able to
utilize accepted statistical methods to extrapolate the results of
these data and recalibrate the DRG weights.@ The manufacturer indicated
that HCFA should reclassify angioplasty cases with platelet inhibitor
therapy on the basis of these data.
Included with the comment are tables summarizing the results of the
commenter's analysis of the data, showing that angioplasty cases
receiving platelet inhibitor therapy are more expensive than those not
receiving platelet inhibitors. According to the commenter, the
approximate average standardized charges for the different classes of
patients are as follows:
No drug, no stent: $19,877.
No drug, with stent: $22,968.
Drug, no stent: $26,389.
Drug, stent: $30,139.
Response: The submission of these data illustrates the problems of
attempting to ensure that non-MedPAR data are reliable, validated, and
feasible to use. Our greatest concern with respect to the data
submitted by the commenter is that we must validate the data to assess
whether they are reliable, and (as explained further below) this
validation process would take significant time and resources because
the data are not readily verifiable.
The data file submitted by the commenter is a MedPAR file with an
additional field. The commenter has ``marked'' certain cases in the
MedPAR file. The file contains variables named REO-FLAG and STENT-FLAG,
which purportedly indicate the case received the platelet inhibitor or
a coronary stent, respectively. However, the variables were placed in
the file by the commenter, based on information that was not made
available to HCFA; we did not receive any information to verify that
the cases flagged by the commenter involved platelet inhibitors.
Although we can use the FY 1998 MedPAR data to validate whether a case
received a coronary stent (because the FY 1998 MedPAR data include the
corresponding procedure code (36.06)), we cannot use the FY 1998 MedPAR
file by itself to validate whether a case involved platelet inhibitors
because the procedure code for the use of platelet inhibitors
(procedure code 99.20) was not effective until October 1, 1998.
Therefore, we cannot validate the data submitted to us without further
investigation.
In order to do so, we believe it is necessary to review the medical
records associated with the cases. Unless the entity submitting the
non-MedPAR data includes medical records (or other information that
would enable us to validate the data), the only method HCFA has to
review medical records is through Peer Review Organization (PRO)
review. Thus, we would need to request assistance in the PRO in each of
the States represented in the submitted data. The PROs would then
contact the hospitals involved to request copies of the medical
records. Finally, based on reviewing those records, the PROs would
notify HCFA whether the data can be validated.
Conducting a PRO independent validation would require a minimum of
2 to 3 months, and possibly much longer. Thus, there is not sufficient
time available to conduct a review of the data submitted by the drug
manufacturer. Since we cannot validate the data, it would compromise
the integrity of the DRG recalibration process to use these data in the
DRG reclassification and recalibration for FY 2000.
We note that the process used by the manufacturer to collect these
data is not specified. Based upon our prior discussions with the
manufacturer and its contractor that prepared the data, we believe the
164 hospitals represented in the sample have a contract for data
analysis and review with the consultant. Although we would not rule out
the possibility that this sample is statistically sufficient, we note
that in general, random sampling is necessary for generalization beyond
the sample itself.
The analysis submitted by the commenter is similar to that
presented in last year's final rule. As we indicated at that time, our
general process of waiting until we have identifiable MedPAR data
applies to changes that would enhance payment as well as those that
would decrease payment. Absent alternative data meeting the criteria
otherwise described in the proposed rule and in this final rule, we
cannot reclassify the administration of platelet inhibitors with
angioplasty (procedure code 99.20) from DRG 112 to DRG 116.
Comment: Some commenters believed that the proposed weights for
DRGs 112 and 116 are dramatically lower than they should be and the
result will be a disincentive to use these technologies.
[[Page 41504]]
Another commenter stated that by not reclassifying cases receiving
platelet inhibitors with angioplasty to DRG 116, we actually promote
the inaccuracy of the DRG weights, by grouping these higher-cost cases
with other lower-cost cases in DRG 112.
Response: With regard to the comment concerning the weights of DRGs
112 and 116, we refer the commenters to the discussion above in section
II.C of this preamble concerning the steps we take in recalibrating the
weights. Every year when the relative weights are recalibrated, we use
charge information from the most recent Medicare data available. That
is, we use the charges reported by hospitals for the cases under each
DRG to establish the relative weights. 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. We
have not identified any problems or anomalies related to the cases in
DRGs 112 and 116 and are confident that the relative weights are
accurate.
With respect to the comment about our promoting the inaccuracy of
the DRG weights by failing to reclassify platelet inhibitor cases, the
commenter does not appear to understand the difference between
reclassification and recalibration. That is, the commenter argues that
the DRG relative weights are inaccurate because high-cost cases are not
reclassified to a higher-weighted DRG. However, our point regarding the
accuracy of the relative weights pertains to the necessity that, in the
process of recalibration, cases are grouped in the DRG to be used for
payment for similar cases during the upcoming year. Thus, the relative
weights are accurate in the sense that they are calculated by grouping
cases according to the DRG under which they would be paid.
Comment: One of the manufacturers of platelet inhibitor therapy
disagreed with our statement in the proposed rule that the prospective
payment system outlier policy would address the rationing of new
technology to Medicare beneficiaries. The commenter argues that cases
of platelet inhibitor therapy would not receive outlier payments
because the cost of the drug, while it is several thousand dollars over
the DRG payment, is not in excess of the fixed loss threshold ($14,575
over the DRG payment in the proposed rule for FY 2000).
Response: 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. Our statement in the proposed
rule was meant to apply to all new technologies, and not specifically
to platelet inhibitor therapy. As stated previously, the prospective
payment system reflects ``averaging principles,'' which means, among
other things, that a hospital might lose money on some cases but will
gain money on other cases; sometimes new technologies lead to lower
costs and we might Aoverpay@ hospitals for those cases. If a case does
not qualify for an outlier payment, then presumably the case falls
within the ``typical'' range of costs for cases in the DRG. We believe
that, as a whole, the prospective payment system does ensure access to
new technologies, including platelet inhibitor therapy.
III. 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 final FY 2000 wage index values in section VI of the Addendum
to this 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).
The final FY 2000 wage index includes the following categories of
data associated with costs paid under the 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 final
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. (As discussed in section
III.C of this preamble, we are refining the methodology for calculating
the wage index for FY 2000.)
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
[[Page 41505]]
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.
Comment: In a general comment on the wage index, MedPac noted that
new measures are needed to implement each new prospective payment
system as well as for Medicare+Choice plans and suggested that we
explore alternative strategies for obtaining labor prices that could be
applied to each type of provider affected. MedPAC offers to assist us
in examining this issue.
Response: We agree with MedPAC that this is an area warranting
further attention to determine whether it is appropriate to continue to
adjust payments for these other provider types based on the relative
average hourly wages of hospital employees, and whether the collection
of wage data for every type of Medicare provider is feasible or
necessary. Currently, the data used to calculate the hospital wage
index is used broadly in payment systems for other types of Medicare
providers. New prospective systems for skilled nursing facilities,
hospital outpatient services, and home health agencies will continue to
use the hospital wage index data for the foreseeable future. We have
collected data separately for skilled nursing facilities, but, pending
further development and auditing of these data, we continue to use the
hospital wage data (before reclassifications by the Medicare Geographic
Classification Review Board) for adjusting skilled nursing facility
payments at this time.
C. FY 2000 Wage Index Methodology Changes
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. Based upon our
analysis of hospitals' FY 1996 wage data, and consistent with the AHA
workgroup's recommendation, we proposed to phase-out these costs from
the calculation of the wage index over a 5-year period. The proposed FY
2000 wage index was 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.
Comment: Commenters unanimously supported our proposal to remove
teaching-related and CRNA costs from the wage index. Further, two
commenters recommended that we emphasize that Medicare pays its share
of teaching-related wage costs through direct graduate medical
education (GME) payments and that these costs are being removed from
the wage index only insofar as Medicare continues to pay the costs
outside of the hospital prospective payment system. Additionally,
commenters favored the proposed 5-year phase-out of these costs to
reduce significant redistributive impacts.
MedPAC, however, recommended that, rather than reducing the weights
for the old calculation and increasing the weights for the new
calculation by the proposed 20 percent each year, we should apply
smaller weights to the new wage index calculation for the first 2
years. Its rationale for this is its concern that inaccurate reporting
of teaching physician data, and our methodology for removing costs for
hospitals that fail to report these data, may inappropriately lower the
wage index values for nonteaching hospitals in the same labor market
areas.
Response: We are pleased to receive strong support for our efforts
to remove from the hospital wage index, wage costs that are associated
with areas of the hospital not included under the hospital prospective
payment system. Therefore, beginning with the FY 2000 wage index, and
over a 5-year period, we are phasing-out costs related to teaching
physicians, residents, and CRNAs. As recommended, we emphasize that our
rationale for removing these costs from the wage index calculation is
that Medicare pays for these costs separately, and these costs will be
excluded from the wage index as long as they are paid separately from
the hospital prospective payment system.
With respect to MedPAC's recommendation that the weight given to
the average hourly wage calculated after removing CRNAs, teaching
physicians, and residents, should be less than 20 percent for FY 2000,
we disagree. If we applied a percentage less than 20 percent for FY
2000 (and FY 2001), we then would have to apply a higher percentage
phase-out in a later fiscal year (or years) and thus increase the
redistributive impact for that year. We believe that applying 20
percent increments each year promotes the smoothest transition to total
exclusion of the costs.
1. Teaching Physician Costs
As discussed in the FY 1999 final rule and the FY 2000 proposed
rule, 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
[[Page 41506]]
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.
Survey data were received from approximately 59 percent of teaching
hospitals reporting physician Part A costs on their Worksheet S-3, Part
II (500 out of 845). Our fiscal intermediaries reviewed 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.
Hospitals were given until March 5, 1999 to request changes to the
initial survey data. Fiscal intermediaries had until April 5, 1999 to
submit the revised data to the Health Care Provider Cost Report
Information system (HCRIS) for inclusion in the May 1999 final wage
data file. Due to the extraordinary effort needed to collect these data
and the importance of accurately removing teaching physician costs, we
allowed hospitals to request revisions to their teaching survey data up
until June 5, 1999.
The hospital industry workgroup also recommended that if the
teaching data collected by the intermediaries are not accurate or
reliable, HCFA should 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. In developing the final FY 2000 wage index (as in the
proposed), 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. These data had been verified by the fiscal
intermediary before submission to us. If we did not have survey data
for a teaching hospital as of June 5, 1999, we removed 80 percent of
the hospital's reported total physician Part A costs and hours for the
wage index.
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 identified 19 of these teaching
hospitals in our final database (there were 72 of these hospitals
identified in the proposed rule). For purposes of calculating the FY
2000 wage index for these 19 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.
We believe this approach is appropriate 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 Worksheet A, Column 1 by the national average
hourly wage for physician Part A costs based upon Line 4 of Worksheet
S-3 (the national average hourly wage is $54.48). We indicate these 19
hospitals by an asterisk in Table 3C of this final rule.
In the proposed rule, we invited comments as to whether the
proposed method 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 were especially concerned that the earliest
cost report on which we would be able to make the necessary changes to
capture the separate reporting of teaching physician Part A costs would
be those submitted for cost reporting periods beginning during FY 1998.
Therefore, we were considering 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.
Comment: Two commenters disagreed with our decision to allow
changes to the teaching survey data but not to corresponding lines on
Worksheet S-3 during the final wage data correction period (June 5
deadline). They believed we should be willing to accept conforming wage
data corrections, even during the final correction period, to achieve
the goal of using the most accurate data available.
Response: If hospitals had miscategorized their teaching physician
costs on their cost report in such a way that accurately completing the
teaching survey would result in their teaching physician survey costs
being removed twice, we did authorize corresponding revisions to
Worksheet S-3. For example, some hospitals included teaching physician
costs in Line 6 of their Worksheet S-3 (which is intended for reporting
interns and residents' costs). Therefore, reporting these costs on
their teaching physician survey, which would be subtracted from Line 4
for the salaries of teaching physicians directly employed by the
hospital, would result in them being removed twice, once when the
teaching physician data are subtracted from Line 1 of Worksheet S-3,
and again when Line 6 of Worksheet S-3 is subtracted from Line 1.
Comment: We received several comments regarding our proposal to use
the teaching survey data for teaching hospitals that submitted surveys
but to remove 80 percent of the total physician Part A costs and hours
for nonresponsive teaching hospitals. Most commenters supported our
reliance on the teaching survey data for the FY 2000 wage index. One
commenter added that we should be assertive in insisting that teaching
survey data be reported accurately by hospitals and verified by fiscal
intermediaries, holding hospitals to a level of accountability that is
similar to the certification of a cost report at filing. Another
commenter urged us to incorporate the separate collection of teaching
physician Part A data into the cost report as soon as possible to
ensure that the data submitted by hospitals is consistent.
Although most commenters agreed that we should reduce reported
total physician Part A costs by 80 percent for teaching hospitals that
do not submit the teaching survey, some took issue with this approach.
One national and one State hospital association recommended we remove
100 percent of reported total physician Part A costs from nonresponsive
teaching hospitals' total costs as a penalty for not reporting their
data. The commenters believe that, for hospitals whose proportion of
teaching physician Part A costs relative to total physician Part A
costs is greater than 80 percent, there is no incentive to complete the
teaching survey. On the other hand, MedPAC recommended that, since
HCFA's preliminary teaching survey data indicate that teaching
physician Part A costs are 68 percent of total physician Part A costs,
we should have adjusted the hospital's data by that amount rather than
the higher 80
[[Page 41507]]
percent figure. MedPAC comments that, although using the 80 percent
figure may give hospitals the incentive to submit the requested survey
data if their ratio of teaching physician Part A costs to total
physician Part A costs is less than 80 percent, that amount could
inappropriately lower the wage index values for other hospitals located
in the same MSA as the nonresponsive teaching hospital. The comments do
acknowledge, however, the policy dilemma in terms of the incentives not
to report that may arise by setting the percentage too low.
Response: We appreciate the commenters' general support of using
the survey data, as well as the efforts of hospitals and the fiscal
intermediaries in this special data collection effort. We believe that,
although the response rate is less than we would have preferred, the
end result is a more accurate FY 2000 wage index.
Although Worksheet S-3 is being revised to provide for the separate
reporting of teaching physician Part A costs, this change will not be
incorporated until cost reporting periods beginning during FY 1998.
Therefore, we will have to conduct another teaching physician cost
survey corresponding with the FY 1997 wage data. We agree with the
commenter's suggestion that the accuracy and completeness of the survey
data should be certified by the hospital in the same manner as the
accuracy and completeness of the cost report data must be certified.
In our calculation of the FY 2000 wage index, we removed 80 percent
of physician Part A costs and hours for teaching hospitals that failed
to report their teaching physician costs. We will consider the comment
to remove 100 percent of these costs for nonresponsive hospitals in the
future, however. Although the 80 percent figure was taken from the
industry workgroup's recommendation, we believe it may be appropriate
to consider raising this percentage to address the problem of hospitals
failing to comply with Medicare instructions.
We appreciate MedPAC's concern that the estimation of teaching
physician costs for hospitals that did not report should not
disproportionately harm other hospitals in the same labor market area.
Similarly, however, these hospitals should not benefit from
noncompliance. Also, as noted previously, because the teaching
physician costs are being removed gradually, with 80 percent of the FY
2000 wage index based on an average hourly wage that includes all of
these costs, we do not believe it is necessary to reduce the 80 percent
estimate to an amount based on the percentage of teaching physician
Part A costs to all physician Part A costs for hospitals completing the
survey to protect other hospitals in the labor market area. Any impact
should be relatively minor for this first year.
Comment: Two commenters believed that hospitals that contract with
physicians for Part A services are disadvantaged because the cost
report and teaching survey instructions seem to be designed only for
hospitals that employ physicians.
Response: The cost report and teaching survey do account for the
costs of contract physicians. The first year contract physician Part A
costs were included in the wage index was FY 1999. Beginning with the
FY 1995 cost report, we revised Worksheet S-3 to allow a separate line
item for reporting these costs. To improve the reporting for all
physician-related wage costs, we made additional changes to the FY 1996
cost report. The teaching survey was patterned after the FY 1996
Worksheet S-3.
The salaries on the Worksheet S-3 for employed physicians derive
from column 1 of Worksheet A. Hospitals should report the labor costs
associated with contract physicians in column 2 of that same worksheet.
If hospitals report their costs properly according to the cost report
instructions, hospitals using contract physicians will not be
disadvantaged by the way the costs are reported. We encourage hospitals
to be diligent in working with their intermediaries if they have
questions about reporting costs on the cost report.
Comment: We received four comments regarding the use of Worksheet
A, Line 23, Column 1 as a proxy for teaching-related wage costs when a
teaching hospital did not report either survey data or any physician
Part A costs. One was favorable without qualifications. One commenter
recommended that, beginning with the FY 2001 wage index, we should
instruct hospitals to report on Worksheet S-3 the wage costs associated
with teaching physicians directly from Worksheet A, Line 23 and the
corresponding hours directly from hospitals' records. A national
hospital association recommended that if we use Worksheet A, Line 23
for teaching salaries and a national average hourly wage for physicians
to estimate the associated hours to be removed for nonreporting
hospitals, then we should apply this approach to all hospitals. If we
apply this method only to hospitals that do not respond to the teaching
survey, the commenter believed that we should penalize nonresponsive
hospitals by increasing the hourly rate by 25 percent to ensure they
are not advantaged by not reporting their costs.
Several hospitals contacted us to report that, although they were
listed as one of the 72 hospitals for whom we used Line 23 of Worksheet
A to remove teaching physician costs, these costs were actually
included in other lines of Worksheet S-3, such as Line 5, Physician
Part B services, or Line 6, Interns and Residents. Therefore, since
both of these lines are subtracted from Line 1 in our calculation,
subtracting Line 23 from Worksheet A would remove these costs twice.
In opposing the use of Line 23 as a proxy for teaching-related
costs, one commenter cautioned that, particularly for hospitals in
States that are prohibited from employing physicians, Line 23, Column 1
may not include any teaching physician costs. MedPAC also stated
concern with this approach, but did not cite any specific problems
associated with it.
Response: For FY 2000, we are removing the amount reported on
Worksheet A, Line 23, Column 1, only in the absence of teaching survey
or Worksheet S-3 data for a hospital but we will continue to explore
using this approach rather than the survey for identifying GME and CRNA
costs to be removed in the FY 2001 wage index. The approach we adopted
has the advantage of being straightforward and easy to apply. Line 1,
Column 1 of Worksheet S-3 is equal to Line 101 of Column 1 of the
Worksheet A. Line 23 of Column 1, which is for the reporting of
nonresidents' costs related to GME that are paid separately from the
prospective payment system, is included in Line 101. Therefore, one
could argue that the simplest way to remove GME costs from the wage
index calculation would be to subtract the costs from Line 1 of
Worksheet S-3 that are attributable to the GME cost centers on
Worksheet A (Lines 22 and 23).
In carving out an estimate of hours for the final 19 hospitals for
which we subtracted Line 23 of Worksheet A from total salaries on
Worksheet S-3, we removed an estimated amount of associated hours based
on the average hourly wage of all physician Part A salaries. We did not
increase this average hourly wage by 25 percent as a penalty for
hospitals that did not otherwise report teaching physician costs. We do
reserve the right to remove some or all of a hospital's wage data that
cannot be appropriately supported by the hospital's records. We also
reserve the right to pursue further action in the case of hospitals
that intentionally withhold, conceal, or otherwise attempt
[[Page 41508]]
to circumvent the cost reporting requirements of their participation
agreements.
If we were contacted timely by a hospital that reported its costs
from Line 23 of Worksheet A somewhere other than Line 4 of the
Worksheet S-3, we did accommodate the hospital's request to avoid
removing the teaching physician Part A costs twice. We note that the
majority of these situations involved hospitals that did not follow the
cost reporting instructions for these costs. Despite MedPAC's general
concerns about this approach to removing costs, we did not receive any
comments that would cause us to rule out this seemingly straightforward
approach for removing GME and CRNA costs from the FY 2001 wage index
for all teaching hospitals. The biggest difficulty seems to be related
to ensuring that the cost reporting instructions are uniformly
followed.
Comment: Two commenters suggested using Worksheet A-8-2 of the cost
report, ``Provider-Based Physicians Adjustments,'' to determine
physician Part A costs, particularly for costs associated with teaching
and contract physicians. The commenters reasoned that, because
Worksheet A-8-2 is used to determine allowable cost and hours to be
included in the Medicare cost report, HCFA should use Worksheet A-8-2
to determine physician Part A labor costs for wage index purposes. Use
of the Worksheet A-8-2 would also ensure the wage index includes only
those physician costs paid under Part A. One of the commenters
commended us for requesting intermediaries to compare the teaching
survey and Worksheet A-8-2 data, but suggested that we should also
require intermediaries to use Worksheet A-8-2 data for determining
teaching physician wage costs when the survey data are unacceptable.
Response: We agree that, if properly completed, Worksheet A-8-2
should be an acceptable source for teaching physician Part A data. In
February, we instructed intermediaries to review hospitals' teaching
survey data for consistency with Worksheet A-8-2, and when necessary,
revise the data accordingly. One minor problem with relying solely on
Worksheet A-8-2 is that it may include some wage-related costs that are
excluded from the wage index calculation; however, these should be
insignificant. We believe that Worksheet A-8-2 is an appropriate source
for physician Part A costs. However, we need to examine Worksheet A-8-2
more closely before requiring that it be used to determine physician
part A costs for future wage indexes.
Comment: We received two comments recommending that we remove
overhead costs associated with the teaching physician, resident, and
CRNA direct costs that are excluded from the wage index. The commenter
compared this action to our current policy in which we remove the
overhead costs associated with excluded providers such as skilled
nursing facilities or rehabilitation units from the wage data. One
commenter offered technical assistance to HCFA in this effort.
Response: We agree, in principle, that overhead costs associated
with teaching-related and CRNA labor costs should be removed from the
wage index calculation in the same way that we remove overhead costs
associated with excluded areas of the hospital. However, we believe
that the methodology we apply for specific patient care cost centers
excluded from the wage data may not be appropriate for removing
overhead related to CRNA and GME costs. Therefore, we are grateful for
the commenter's offer of technical assistance to develop an appropriate
methodology for allocating overhead costs related to CRNAs and GME. We
anticipate that this issue will be discussed by HCFA's wage index
workgroup later this year, and in next year's proposed rule for FY
2001.
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 on
Worksheet S-3 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, therefore, we proposed and are now implementing the
removal of CRNA and resident costs over a 5-year period, beginning with
the FY 2000 wage index.
We received no comments related to this change.
3. Transition Period
The FY 2000 wage index is based on a blend of 80 percent of
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.
Comment: One hospital believed that it has been disadvantaged by
HCFA's allowance of contract teaching physician Part A costs in the FY
1999 wage index, and that HCFA should disallow teaching physician costs
entirely, beginning with FY 2000. The hospital stated that it is
experiencing difficulty meeting the criteria for geographic
reclassification for purposes of the wage index to another MSA that
includes a teaching hospital that reports a large amount of contract
teaching physician Part A costs.
Response: Our reasons for including contract physician Part A costs
are discussed in detail in the July 31, 1998 Federal Register (63 FR
40967). In general, it was our belief that if contract physician Part A
costs were reliably reported by hospitals, they should be included in
the wage data along with the Part A costs of directly employed
physicians. In that final rule, we also discussed 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. Therefore, based on
data we have collected since that final rule was published, and as
discussed above, we are removing teaching physician costs (as well as
CRNA and resident costs) for the wage data, over a 5-year period.
As is generally true with changes in the wage index, hospitals that
may have once been eligible to reclassify to another MSA for purposes
of the wage index may find that they no longer qualify after changes
have been implemented. However, we believe that all our changes to the
wage index are designed to more accurately reflect the wage costs
incurred by hospitals. In the case of the teaching physician costs, we
[[Page 41509]]
believe that a 5-year phase out is appropriate to reduce significant
redistribution impacts. With regard to the accuracy of the teaching
hospital data, the intermediary verified the data and determined it is
consistent with audit findings.
D. Verification of Wage Data from Medicare Cost Reports
The data for the 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 final wage index includes FY 1996 data submitted
to 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. In the proposed rule, we discussed
our review and methodology for resolving questionable elements in the
hospital data (64 FR 24728). The revised data are reflected in this
final rule. Since the proposed rule, we deleted data for four hospitals
that reported aberrant and unverifiable wage data that would have
significantly distorted the wage index values, and added data for seven
hospitals that were not included in the proposed wage index but rather
whose data have now been corrected and verified. The final FY 2000 wage
index is calculated based on FY 1996 data for 5,038 hospitals.
Comment: One hospital association expressed concern that a number
of hospitals might have failed to comply with the new cost reporting
instructions for wage-related costs, causing an overreporting of these
costs in the FY 2000 wage index. Prior to the FY 1996 cost report, the
lines on Worksheet S-3 for core and other wage-related costs reflected
a hospital's total costs for those categories. However, beginning with
the FY 1996 cost report, core and other wage-related costs must be
reported net of costs associated with excluded areas. The commenter
stated that wage-related costs for a significant number of hospitals
increased at least 10 percent this year and it believed that the
increase is due to hospitals incorrectly reporting excluded area wage-
related costs on Line 13. The commenter recommended that we develop a
method to determine if a hospital misreports its wage-related costs,
and that we should require correction of the data.
Response: We believe the new cost reporting instructions for wage-
related costs, Lines 13 and 14 of Worksheet S-3, Part II, are clear
regarding the exclusion of costs associated with excluded areas.
Intermediaries were aware of the new cost reporting instructions and
instructed their auditors to closely examine the costs reported in
Lines 13 and 14 of Worksheet S-3, Part II for compliance. In addition,
the intermediaries' FY 1996 wage data review program included an edit
for hospitals having wage-related costs that increased 10 percent or
more between FY 1995 and FY 1996. Furthermore, we contacted
representatives of national hospital associations who agreed to alert
their members of the reporting change. We are aware of numerous
instances where intermediaries adjusted hospitals' wage-related costs
after review. As part of the FY 1997 wage data desk review program (for
the FY 2001 wage index), we will provide more specific instructions to
the intermediaries to review the data reported for core and other wage-
related costs to ensure no costs associated with excluded areas are
included.
Comment: One commenter disagreed with the approach we used in the
proposed rule to identify teaching hospitals to ensure that all of
these hospitals had reported teaching physician survey data. We based
our decision to remove either 80 percent of physician Part A costs and
hours or the amount on Line 23, Column 1 of Worksheet A, based on
whether the hospital had a resident-to-bed ratio greater than zero on
the latest Provider-Specific File. The commenter suggested it would be
more appropriate to base the identification of teaching hospitals on
whether the hospital reported residents on its cost report for the
period corresponding with the wage data.
Response: We agree with this comment. It is more appropriate to
base the identification of teaching hospitals on data from the same
year as the wage data we use. Therefore, we revised our method to
identify teaching hospitals based on whether they reported residents
during their cost reporting period beginning during FY 1996.
Comment: One State hospital association commented that the
underrepresentation of physician Part A costs for hospitals in its
State is due to the intermediary's exclusion of a majority of the costs
reported by hospitals. The commenter believes there are inconsistencies
between the two intermediaries that service hospitals in the State in
their treatment of contract physician Part A costs. The commenter
recommended that HCFA monitor intermediaries and enforce uniform
application of Medicare principles and standards, particularly with
regard to the determination of allowable physician costs on Worksheet
A-8-2.
Response: For wage index purposes, contract physician costs are to
be reported according to the instructions for Worksheet S-3 Part II,
Line 10. The physician Part A costs reported on Worksheet S-3 may
differ slightly from those reported on worksheet A-8-2 because there
are minor differences in the types of wage-related costs that are
allowed for each of the worksheets. The two forms serve different
purposes. The wage index worksheet (S-3) may include, to a reasonable
extent, the actual costs a hospital incurs. However, Worksheet A-8-2 is
used to determine allowable costs for Medicare cost report purposes and
includes cost limits. The commenter did not indicate exactly what
inconsistencies it had found. If there are inconsistencies, we would
like to address them as soon as possible for the FY 2001 wage index.
We note that, intermediaries have informed us that hours associated
with contract physicians are often difficult to verify because
hospitals have not developed reporting systems that accurately account
for contract physician hours. Consistent with Medicare policy,
intermediaries must exclude costs and other data that are
insufficiently supported by a hospital's documentation.
Comment: One commenter noted several errors in the proposed rule
and final wage data public use file. The commenter stated that Table 3C
of the proposed rule included some hospitals with extremely low average
hourly wages, and that the average hourly wages reported for some
hospitals marked with an asterisk do not seem to incorporate the
Worksheet A, Line 23 data as described in the footnote. Additionally,
the commenter stated that the final wage data on the Internet includes
two different date formats for fiscal year begin and end dates, an
eight digit format and a seven digit format. The commenter asked that
HCFA make the appropriate corrections in the final wage index
calculation.
Response: We were informed shortly after publication of the
proposed rule that there were several errors in Table 3C, including
those noted by the commenter. As a result, we issued a revised Table 3C
in a correction notice published in the Federal Register on June 15,
1999 (64 FR 31995). Although the extremely low average hourly wages
still appear in Table 3C of the correction notice just as they were
reported by the hospitals, the aberrant data were either corrected or
deleted in the final wage index calculation. All other errors
identified in Table 3C were corrected through the June 15 notice. Also,
fiscal year beginning and ending dates that appear in a 7-digit date
format in the final wage data public use file were
[[Page 41510]]
corrected to an 8-digit date format in the final calculation.
E. Computation of the Wage Index
The method used to compute the FY 2000 wage index is as follows:
Step 1--As noted above, we based 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
detailed 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 ensures 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
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 costs and hours 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 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
[[Page 41511]]
wage (using the same blending methodology described in Step 7). Using
the data as described above, the national average hourly wage is
$21.1800.
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. We note that on July 6, 1999, OMB announced the designations of two
new MSAs: Auburn-Opelika, Alabama, comprising Lee County, and
Corvallis, Oregon comprising Benton County.
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
$9.86756 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 ensure 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 226 hospitals in 36 MSAs. The MSAs affected by this provision
are identified in Table 4A by a footnote.
Comment: Two commenters suggested that, given the complexity of the
FY 2000 wage index calculation, we should make our detailed calculation
procedures and edits publicly available. This would enable hospitals
and researchers to more easily replicate the wage index values. One of
the commenters recommended that the detailed calculations and methods
should be included in future proposed and final rules. In addition,
they requested that we release the actual computer program used to
calculate the wage index.
Response: We have fully explained the steps we take to calculate
each hospital's average hourly wage and the wage index. In addition, we
have worked with hospitals that contacted us after attempting to
replicate our calculations, by reviewing their results and identifying
discrepancies. In doing so, we have been able to identify certain
anomalies in some of the proposed wage index values, which have been
corrected in the final wage index. Therefore, we agree that it might be
useful to provide more information to make it easier for the public to
replicate our calculations, and we are exploring our options. However,
we do not generally provide our computer programs that are used to
perform the wage index calculations, or for that matter, the programs
we use for all other calculations we perform.
Comment: One commenter recommended that, for leap years HCFA should
use 366 days, rather than 365 days, when annualizing cost report data
(see step 5 of the wage index calculation).
Response: We agree that the commenter's recommended method of
annualization, which recognizes an additional day for leap years, is
theoretically more accurate than our simple, across-the-board approach.
However, due to the intense effort required to incorporate all of the
wage data changes processed in conjunction with hospitals' final
opportunity to request revisions, we were unable to evaluate and
incorporate this change into our computer program in time to be
reflected in the final FY 2000 wage index. Therefore, we are not
adopting this recommendation for the FY 2000 wage index calculation. We
would note that, as described in step 5 above, we annualize any cost
reporting period that covers a period of fewer than 360 days or more
than 370 days. The majority of cost reporting periods are not
annualized. In those instances where annualization is done, we would
further point out that it does not affect the hospital's average hourly
wage calculation, since both the costs and hours are annualized by 365.
The impact, therefore, of this commenter's suggestion is limited to the
calculation of the labor market area average hourly wage. Furthermore,
if we were to account for the additional day of a leap year in our
annualization, the impact on any particular area's average hourly wage
could be either positive or negative.
F. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more MSAs are considered to be located in
one of the adjacent MSAs if certain standards are met. Under section
1886(d)(10) of the Act, the Medicare Geographic Classification Review
Board (MGCRB) considers applications by hospitals for geographic
reclassification for purposes of payment under the prospective payment
system.
The methodology for determining the wage index values for
redesignated hospitals is applied jointly to the hospitals located in
those rural counties that were deemed urban under section 1886(d)(8)(B)
of the Act and those hospitals that were reclassified as a result of
the MGCRB decisions under section 1886(d)(10) of the Act. Section
1886(d)(8)(C) of the Act provides that the application of the wage
index to redesignated hospitals is dependent on the hypothetical impact
that the wage data from these hospitals would have on the wage index
value for the area to which they have been redesignated. Therefore, as
provided in section 1886(d)(8)(C) of the Act, the wage index values
were determined by considering the following:
If including the wage data for the redesignated hospitals
would reduce the wage index value for the area to which the hospitals
are redesignated by 1 percentage point or less, the area wage index
value determined exclusive of the wage data for the redesignated
hospitals applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals
reduces the wage index value for the area to which the hospitals are
redesignated by more than 1 percentage point, the hospitals that are
redesignated are subject to that combined wage index value.
If including the wage data for the redesignated hospitals
increases the wage index value for the area to which the hospitals are
redesignated, both the area and the redesignated hospitals receive the
combined wage index value.
The wage index value for a redesignated urban or rural
hospital cannot be reduced below the wage index value for the rural
areas of the State in which the hospital is located.
Rural areas whose wage index values would be reduced by
excluding the wage data for hospitals that have been redesignated to
another area continue to have their wage index values calculated as if
no redesignation had occurred.
Rural areas whose wage index values increase as a result
of excluding
[[Page 41512]]
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
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 final revised wage index values for FY 2000 are shown in Tables
4A, 4B, 4C, and 4F in the Addendum to this final 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 final rule includes
the adjusted average hourly wage for each hospital based on the FY 1996
data (as calculated under Steps 4 and 5 above). The MGCRB will use the
average hourly wage published in the final rule to evaluate a
hospital's application for reclassification 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 these 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 the proposed wage index was constructed, the MGCRB had
completed its review of FY 2000 reclassification requests. Therefore,
the proposed FY 2000 wage index values incorporated 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. In
this final rule, we have incorporated changes to the wage index that
occurred after the proposed wage index was calculated and that resulted
from withdrawals of requests for reclassification, wage index
corrections, appeals, and the Administrator's review process. 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 the proposed rule. To be effective in FY 2000, the
request for withdrawal of an application for reclassification had to be
received by the MGCRB by June 21. A hospital that requests to withdraw
its application may not later request that the MGCRB decision be
reinstated.
G. Wage Data Corrections
In the proposed rule, we stated that, to allow hospitals time to
evaluate the wage data used to construct the proposed FY 2000 hospital
wage index, we would make available in May 1999 a final public data
file containing the FY 1996 hospital wage data.
The final wage data file was released on May 7, 1999 (amended on
May 14). As noted above in section III.C of this preamble, this file
included hospitals' teaching survey data as well as cost report data.
As with the file made available in February 1999, we made 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 was 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 the hospital
could not have known about before the release of the final wage data
public use file, not for the initiation of new wage data correction
requests.
If, after reviewing the May 1999 final data file, a hospital
believed that its wage data were incorrect due to a fiscal intermediary
or HCFA error in the entry or tabulation of the final wage data, it was
provided an opportunity to send a letter to both its fiscal
intermediary and HCFA, outlining why the hospital believed an error
exists and provide all supporting information, including dates. These
requests had to be received by us and the intermediaries no later than
June 7, 1999.
Changes to the hospital wage data were 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 also allowed hospitals to
request changes to their teaching survey data. These requests had to
comply with all of the documentation and deadline requirements
specified in the May 7, 1999 proposed rule.) Specifically, neither the
intermediary nor HCFA accepted 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) are incorporated into the final wage index in this final
rule, to be effective October 1, 1999.
We believe the wage data correction process provides hospitals with
sufficient opportunity to bring errors in their wage data to the
intermediary's attention. Moreover, because hospitals had access to the
final wage data by early May 1999, they had 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 and
its
[[Page 41513]]
implementation on October 1, 1999. If hospitals avail themselves of
this opportunity, the FY 2000 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 had the
opportunity to verify its data, and the intermediary notified 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 September 1, 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
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.
Comment: One commenter suggested that our notices of the wage index
review process should be more explicit regarding dates, titles, and
addresses, and should be presented in a format similar to the request
for hearing language contained in most Notices of Program
Reimbursements. The commenter believes this would avoid confusion and
misunderstandings throughout the process.
Response: Although we believe that our notices of wage index file
availability are already quite detailed, we agree they might be
improved to minimize misunderstandings. For example, we intend to
continue to work with our intermediaries to ensure that, in their
correspondence with hospitals regarding the resolution of revision
requests submitted by the hospitals, the intermediaries state more
explicitly the criteria, procedures, and deadlines for requesting our
intervention when a hospital disagrees with an intermediary's policy
determination. We welcome any other specific recommendations.
Comment: One commenter requested that we consider providing a mid-
year correction, as in the FY 1999 wage index, for those areas that are
affected by a major change in the FY 2000 wage index. The commenter
stated that further opportunity to review and adjust its wage data
would provide a more meaningful wage index.
Response: As we stated in the February 25, 1999 final rule
implementing changes resulting from the limited window of opportunity
for hospitals to request revisions to their FY 1995 data used to
calculate the FY 1999 wage index, we believe our usual procedures
provide ample opportunity for diligent hospitals to ensure the accuracy
of their wage data (64 FR 93781). The limited opportunity to request
revisions to the data used to calculate the FY 1999 wage index was
based on a combination of circumstances unique to that year, and
hospitals should assume in the future that all requests to change their
wage data must conform to the well-established guidelines discussed
above. Therefore, we do not intend to again provide such a special
opportunity for further revision requests.
IV. Other Decisions and 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 an 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 an 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, in the May 7, 1999 proposed rule, we
proposed to continue to apply the MSA definition of an urban area for
SCH status purposes.
We proposed 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 indicator 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
[[Page 41514]]
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 an
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.
We received one comment on our proposed retention of this
definition.
Comment: One commenter, which had been communicating with us before
the issuance of the proposed rule, continued to express concern about
our policy of defining urban areas for SCH purposes based on MSAs. The
commenter raised several points. First, the commenter stated that our
discussion in the proposed rule is ``misleading'' because it did not
mention recent litigation on this issue. Second, the commenter argued
that our proposal is flawed because it results in inequitable treatment
of hospitals; that is, it renders a hospital's ability to qualify as an
SCH dependent on OMB's reconfiguration of MSA boundaries, and patients'
ability to access inpatient hospital services is not affected by those
boundaries. Third, the commenter questioned two aspects of our
rationale for retaining an MSA-based definition of the urban areas in
the SCH context--that OMB considers commuting patterns when defining
MSAs and that use of MSAs is consistent with the methodology we use for
computing the standardized amounts. Finally, the commenter suggested
that, if we decided to adopt our proposal to base the definition of
urban areas for SCH purposes on MSAs, we should at least adopt an
exception to that rule under which a hospital that is the only hospital
in an MSA could still qualify as an SCH.
Response: We do not agree with the commenter that we should either
abandon our longstanding policy of defining urban areas for SCH
purposes based on MSAs or adopt the exception to that policy that the
commenter suggests. Although the commenter is correct in pointing out
that there has been recent litigation involving our definition of
``urban area'' for SCH purposes, we do not believe that our proposal
was in any way misleading. Partly as a result of the litigation, we
decided to reiterate and clarify our policy. Thus, we clearly stated in
the proposed rule that we proposed to retain our longstanding
definition in favor of other definitions based on the Census Bureau's
urbanized areas or on HFPAs and explained the reasons for our proposal.
We believe the proposed rule, therefore, gave interested parties more
than adequate notice of the issue and afforded them the opportunity to
comment.
We continue to believe that it is appropriate to adopt an MSA-based
definition of urban areas for SCH purposes for the reasons stated in
the proposed rule and in our earlier discussions of the MSA-based
definition. The commenter gave an example of a situation in which an
urban hospital is the nearest like hospital to a rural hospital, and
the rural hospital is likewise the nearest hospital to the urban
hospital. The commenter stated that the rural hospital could obtain SCH
status, but the urban hospital could not, which, the commenter
concluded, results in inequitable treatment of similarly situated
hospitals.
We do not agree with this conclusion for several reasons. First, if
the urban hospital was located more than 35 miles from the rural
hospital, it could in fact qualify for SCH status under our rules.
Moreover, the hospitals in this example are not similarly situated; one
is urban and one is rural. As we have stated previously, urban areas
generally have better roads, faster snow clearing, and more available
hospitals, factors that affect access to inpatient hospital services.
(See 56 FR 25483 (June 4, 1991).) Thus, even if the rural hospital in
the commenter's example qualified as an SCH and the urban hospital did
not, the difference in result is justified by the hospitals' different
geographic circumstances.
The commenter's example does nothing to demonstrate that any other
definition of an urban area for SCH purposes is preferable to an MSA-
based definition. The somewhat unique situation the commenter
described--an urban hospital that is closest to a rural hospital and
vice versa--could arise no matter what definition of urban area we
adopt.
Similarly, while the commenter objected to hospitals' ability to
qualify for SCH status depending on possible shifting OMB definitions
of MSAs, the same objection could be made of any definition of urban
area that adopts geographic delimiters promulgated by another entity--
including Census Bureau urbanized areas or HFPAs. In addition, we
consider the fact that OMB occasionally revises the MSA boundaries to
be a strength of that scheme. We think it is appropriate that any
definition of urban areas for SCH purposes be reviewed periodically to
take into account changes that have occurred in various areas'
characteristics. Urban and rural areas do not remain static forever.
Shifts in population and other changes can transform previously rural
areas into urban ones, and vice versa. Because we believe the nature of
an area as urban or rural is an important part of determining whether a
hospital should qualify as an SCH, the mechanism for making those
determinations should be able to account for changes in that nature.
As noted above and in our previous discussions of this issue, we
believe that several factors make urban hospitals more accessible to
patients than rural ones. Contrary to the commenter's statement that
access is not affected by MSA boundaries, we proposed to adopt MSAs as
the definition of urban areas for SCH purposes precisely because MSAs
provided a good gauge of the presence of factors affecting access. The
commenter's contentions fail to convince us that we should not adopt
this proposal.
The commenter also argued that we have not properly considered
reasonable alternatives to our proposed MSA-based definition of urban
areas for SCH purposes. To the contrary, we specifically considered and
proposed to reject two alternative definitions based on urbanized areas
and HFPAs. The commenter offered no additional alternatives. Rather,
the commenter questioned our reliance on OMB's use of commuting
patterns in establishing MSAs, and stated that both urbanized areas and
HFPAs also consider commuting patterns in the form of such factors as
availability of roads and travel time and distance. Even if true,
however, that means only that all three potential definitions consider
commuting patterns in some form, and thus does not provide a basis for
preferring a definition of urban areas other than one based on MSAs.
The commenter pointed out that the
[[Page 41515]]
commuting patterns OMB analyzes pertain to commutes to workplaces,
which, the commenter claimed, do not relate to access to hospital
services. However, we have indicated that we deem commuting patterns
important because they indicate access to areas in which hospitals are
located. (See 48 FR 39780 (Sept. 1, 1983).) As such, they are a good
indicator of access to hospital services.
The commenter questioned our reliance on the fact that MSAs are
used as the basis for determining the standardized amounts that form
the basis of prospective payment system payments. The MSAs also supply
the definition of urban areas used for virtually every other purpose
under the hospital inpatient prospective payment system, including
other special status determinations, geographic reclassification, and
calculation of the wage index. We continue to believe that it is
appropriate to use a definition of urban areas for SCH purposes that is
consistent with the definition used for almost all other components of
the prospective payment rates.
In regard to the commenter's suggestion that, if we retain the MSA-
based definition of urban areas for SCH purposes, we adopt an exception
to that definition under which an urban hospital that is the only
hospital in its MSA would qualify as an SCH if it would otherwise
qualify absent its urban location. We note that, to a large extent, we
already apply this rule. As noted above, an urban hospital that is more
than 35 miles from the nearest like hospital may qualify as an SCH
notwithstanding its urban location. Thus, urban hospitals, including
those in a sole-hospital MSA, can in fact qualify as SCHs, provided
they are not in close proximity to another like hospital.
We acknowledge that a small number of MSAs may contain only one
hospital; however, we have stated that urban areas generally have more
available hospitals (56 FR 25483 (June 4, 1991)). Again, urbanized
areas, HFPAs, or an urban area defined under any other methodology
might also contain only one hospital. As a result, there is nothing
inherent in our adoption of an MSA-based definition that compels
adoption of the exception the commenter has proposed. It continues to
be our judgment that an urban hospital within 35 miles of another like
hospital is not the ``sole'' source of inpatient hospital services in
its community, given the close proximity of the other hospital and the
other factors affecting increased access to inpatient hospital services
that location in an urban area denotes. Thus, we have not adopted the
commenter's proposed exception to the rule defining urban areas based
on MSAs for SCH purposes.
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
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 in
the May 7, 1999 proposed rule included all urban hospitals nationwide,
and the proposed regional values were 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 were 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 proposed 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. (See the table set forth in the May 7, 1999
proposed rule at 64 FR 24732-24733.)
Based on the updated FY 1998 MedPAR file, which contains data from
additional bills received through March 31, 1999, the final national
case-mix value is 1.3438 and 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).................... 1.2498
2. Middle Atlantic (PA, NJ, NY)............................ 1.2499
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 1.3306
4. East North Central (IL, IN, MI, OH, WI)................. 1.2577
5. East South Central (AL, KY, MS, TN)..................... 1.2795
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 1.1877
7. West South Central (AR, LA, OK, TX)..................... 1.2994
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 1.3438
9. Pacific (AK, CA, HI, OR, WA)............................ 1.3231
------------------------------------------------------------------------
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 VI of the Addendum to this final 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.
[[Page 41516]]
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. In the May
7, 1999 proposed rule, we proposed to update the regional standards.
The proposed regional standards were 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 proposed 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. (See the table set forth in the May 7, 1999 proposed
rule at 64 FR 24733.)
Based on the latest discharge data available for FY 1997, the final
median number of discharges for urban hospitals by census region areas
is as follows:
------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................... 6733
2. Middle Atlantic (PA, NJ, NY)............................ 8655
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 7845
4. East North Central (IL, IN, MI, OH, WI)................. 7499
5. East South Central (AL, KY, MS, TN)..................... 6832
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 5346
7. West South Central (AR, LA, OK, TX)..................... 5380
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 8026
9. Pacific (AK, CA, HI, OR, WA)............................ 6151
------------------------------------------------------------------------
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.
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.
Comment: One commenter urged HCFA to reconsider its decision not to
restore RRC status to those hospitals located in areas that have been
redesignated as urban by the OMB. The commenter argued that the statute
established only one qualification for having a hospital's RRC status
restored; that is, a hospital must have been designated as an RRC in FY
1991. According to the commenter, the statute provides no other
conditions, nor does it provide HCFA with the discretion to create
other conditions. The commenter believes that our decision not to
restore the RRC status of hospitals located in areas redesignated as
urban by OMB effectively requires affected hospitals to satisfy an
additional condition that they be located in a rural area.
Response: We responded to a comment raising the same issue in the
May 12, 1998 final rule (63 FR 26326). We addressed our interpretation
of section 4202(b)(1) of the BBA in the August 29, 1997 final rule with
comment period (62 FR 45999 and 46000) as well as the May 12, 1998
final rule, and we refer the reader to those documents.
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 BBA 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 proposed to revise Sec. 412.105(f)(1)(iii) to correct
these cross-references.
We did not receive any comments on this proposal and are adopting
it as final.
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 proposed 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 proposed 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).
We did not receive any comments on this proposal and are adopting
it as final.
We note that the instructions for preparing applications for FY
2001 individual and group reclassifications, which are due to the MGCRB
by September 1, 1999, are now available for downloading from the
Internet at www.hcfa.gov/regs/appeals.
Comment: One commenter requested clarification about submitting an
application for reclassification for the standardized amount when the
payment rates had changed during the year for which the applicable cost
report would be used. Specifically, the commenter was concerned that
the revised average hourly wage data, wage index, and standardized
amounts applicable for FY 1999 beginning on or after March 1, 1999 (see
the final rule published on February 25, 1999 (64 FR 9378)) will
require the MGCRB to determine which
[[Page 41517]]
wage index and standardized amount value to use when evaluating
applications seeking standardized amount geographic reclassification.
The commenter asserted that because the MGCRB must use historical
national adjusted operating standardized amounts and wage indices, a
problem potentially arises when HCFA calculates more than one
standardized amount and wage index for an area in a year, as it did in
FY 1999. The commenter suggested the MGCRB use prorated standardized
amount and wage index values in evaluating applications.
Response: When the MGCRB evaluates an application for
reclassification for the standardized amounts, it uses actual payment
rates for actual periods. Therefore, if the payment rate changed during
the year that applies to a hospital's application, those figures are
incorporated into the calculation for the months during which they
applied. The same policy holds true for wage data.
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, in the
proposed rule, we proposed to clarify certain GME policies and also
make some technical changes to the regulations text. In addition, we
proposed certain changes in GME policy.
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 proposed 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 proposed to make a conforming change to
Sec. 413.86(g)(1)(iii) to recognize approved geriatric programs
accredited by all national approving organizations.
We received one comment in support of our proposed revision to
Sec. 413.86(b). We are adopting the revision as final.
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 proposed 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.
Comment: Many commenters supported our technical change under the
proposed Sec. 413.86(f)(4)(iii), which provides that, in order to count
residents training at a nonhospital site for purposes of direct and
indirect GME payment, the hospital must actually incur all or
substantially all of the costs for the training programs. However, we
believe several commenters misunderstood our technical change. The
commenters believed that the change was unnecessary because the
existing regulations, which were issued in the July 31, 1998 final
rule, provide adequate guidance for purposes of the hospital claiming
direct and indirect GME for resident training in the nonhospital site.
Response: We proposed to make the technical change in
Sec. 413.86(f)(4)(iii) for two reasons. First, we stated in the
preamble to the July 31, 1998 final rule that we are requiring the
hospital to actually incur all or substantially all of the cost, but
the regulation text only indicated that the hospital must have an
agreement to incur the cost; that is, the regulation text did not
include specific language requiring that the hospital actually incur
the cost. Second, we defined the phrase ``all or substantially all'' in
Sec. 413.86(b) but inadvertently omitted using the phrase in the policy
specified in Sec. 413.86(f)(4).
Comment: In regard to our proposed technical change to the
nonhospital payment policy as specified in Sec. 413.86(f)(4)(iii), one
commenter asked us to define the difference, if any, in our use of
``nonprovider'' entity and ``nonhospital'' entity. In addition, the
commenter asked whether a skilled nursing facility or a unit excluded
from the prospective payment system is considered to be a nonhospital
setting.
Also, similar to the public comments addressed in the in July 31,
1998 final rule, several commenters asked us to clarify whether
hospitals would still be eligible to receive payments in situations
where the teaching faculty volunteers their services and neither the
hospital nor the nonhospital entity
[[Page 41518]]
incurs costs for supervisory teaching physicians. The commenters asked
us to continue to support the following statement that we included in
the July 31, 1998 final rule (63 FR 40996) allowing hospitals to remain
eligible for payment in such situations where supervisory physicians in
the nonhospital site are volunteering their time: ``for the purposes of
satisfying the requirement of a written agreement, the written
agreement between a hospital and a nonhospital site may specify that
there is no payment to the clinic for supervisory activities because
the clinic does not have these costs.''
Response: For purposes of our nonhospital payment policy for GME in
Sec. 413.86(f)(4), we use the terms ``nonhospital'' and ``nonprovider''
interchangeably. A free-standing SNF (that is, a SNF that is not part
of a hospital) is a nonhospital site. An excluded unit of a hospital is
not a nonhospital site because an excluded unit is still part of a
hospital.
We will continue a volunteer supervisory physician policy
consistent with the policy stated in the July 31, 1998 final rule, as
requested by the commenter. Hospitals may receive payment for the costs
of training residents in the nonhospital site even though the hospital
might not be incurring any costs for supervisory physician activities.
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 the 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. In the May 7, 1999 proposed rule, we proposed
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 proposed 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 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 proposed 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 for both hospitals 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. In the
May 7, 1999 proposed rule, we proposed 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 proposed 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 past, had terminated their
participation before 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 proposed 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 proposed 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 proposed 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
[[Page 41519]]
on or before August 5, 1997. Existing 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 proposed 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
proposed 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 proposed 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 proposed 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 proposed 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
proposed to add the words ``allopathic and osteopathic'' in
Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) before the word
``resident.''
We received a number of comments on our proposals.
Comment: One commenter supported our technical changes to the new
residency program adjustments under proposed Secs. 413.86(g)(6)(i) and
413.86(g)(6)(ii). The commenter agreed with our technical change of
referencing ``allopathic and osteopathic residents'' instead of simply
``residents.''
The proposed rule specified that the method for calculating the
adjustment to the cap 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 year program based on the minimum accredited
length for the type of program. One commenter requested an example of a
calculation of this adjustment.
Response: In response to the commenter's request, we are providing
the following example of how to calculate the new residency program
adjustment under Sec. 413.86(g)(6)(ii). This example was included in a
Program Memorandum (Transmittal No. A-97-13 (p. 16), September 1997)
that transmitted billing instructions to our fiscal intermediaries.
Example: Assume a hospital had an unweighted direct GME count of
100 FTE residents for its cost reporting period ending June 30, 1996
and the hospital, although it had 6 first year slots, began an internal
medicine program on July 1, 1995 with 4 first year residents (who were
included as part of the 100 FTE cap). On July 1, 1996, the program
expands to 10 residents (6 first year and 4 second year residents.) On
July 1, 1997, the program has 16 residents (6 first year residents, 6
second year residents, and 4 third year residents). Since the minimum
accredited length for internal medicine program listed is 3 years, the
hospital's unweighted FTE cap can be adjusted based on 18 residents in
the internal medicine program (6 first year residents * 3 years). In
the hospital's cost reporting period ending June 30, 1996, the hospital
had a total of 100 FTE residents including 4 in internal medicine. The
hospital's cap can be adjusted up to 14 residents (18 internal medicine
residents less 4 already included in the fiscal year ending June 30,
1996 FTE count).
Comment: Several commenters expressed concern about our definition
of ``new medical residency training program'' for purposes of
determining the FTE cap adjustment under Sec. 413.86(g). One commenter
raised questions regarding the situation where the original sponsor of
a residency program has been notified that it has lost its
accreditation and a new sponsor assumes the training of all or most of
the residents of an existing program. The commenter believed that the
program under the new sponsor should be treated as ``new'' as well.
Another commenter suggested we have interpreted ``new residency
program'' to be simply a new site for a residency program that may have
been in existence at other clinical sites in the past.
Response: Under the existing Sec. 413.86(g)(7) (proposed to be
redesignated as Sec. 413.86(g)(9)), we define ``new medical residency
training program'' to be a program ``that receives initial
accreditation by the appropriate accrediting body or begins training
residents on or after January 1, 1995.'' The language ``begins training
residents on or after January 1, 1995'' means that the program may have
been accredited by the appropriate accrediting body prior to January 1,
1995, but did not begin training in the program until on or after
January 1, 1995. The language does not mean that it is the first time a
particular hospital began training residents in a program on or after
January 1, 1995, but the program was in existence at another hospital
prior to January 1, 1995, as the commenter suggests.
We believe there may be some confusion on the part of the
commenters as to how to determine when a hospital may receive an
adjustment to its FTE cap for a new residency program. The definition
can be more easily understood if we explain the application in two
steps. First, determine if the hospital's residency program qualifies
to be ``new'' under Sec. 413.86(g)(9). Second, once the residency
program is determined to meet the definition of ``new,'' apply the
criteria under Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) to determine
whether a hospital's new program qualifies for an adjustment to its FTE
cap. A hospital's sponsorship of the program plays no role in
determining whether a hospital qualifies to receive an adjustment under
either Sec. 413.86(g)(6)(i) or Sec. 413.86(g)(6)(ii).
If two hospitals ``merge'' separate residency programs, the single
residency program resulting from the merger would not be considered
``new'' for purposes of either hospital receiving an adjustment to its
FTE cap. The programs have already been in existence and, presumably,
the hospitals have been able to count the residents training in each
individual program as part of the hospitals' respective FTE caps. If
the hospital that is training the residents in the merged program would
like to receive an adjustment to its FTE cap for the added residents it
presumably now trains, that hospital may wish to affiliate for purposes
of establishing an aggregate FTE cap.
Comment: We received several comments on our clarification on how
to account for situations when residents spend an entire program year
(or years) at one hospital and the remaining year (or years) of the
program at another hospital (or hospitals) during the first 3
[[Page 41520]]
years of the new residency program. We stated that, 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 of the program. One commenter asked us to clarify the adjustment
to the cap in situations where the residents rotate to multiple sites
in a single program year during the first 3 years of a new residency
program--that is, the residents rotate to other hospitals for partial
years. Another commenter requested that we give examples of how to
calculate the FTE cap adjustment in these situations.
Response: In situations where residents spend an entire program
year (or years) at one hospital and the remaining year (or years) of
the program at another hospital during the first 3 years of the new
residency program, each hospital that trains the residents receives an
adjustment to its cap based on the product of the highest number of
residents in any program years during the third year of the first
program's existence and the number of years that the residents are
training at each respective hospital. In situations where the residents
spend partial years at different hospitals during the first 3 years of
the new residency program, each hospital that trains the residents
receives an adjustment to its cap based on product of the highest
number of residents in any program year during the third year of the
first program's existence and the minimum accredited length of the
program.
In response to the second commenter's request, the following are
some examples as to how to calculate the adjustment to the FTE cap for
a new residency program in situations where residents spend an entire
program year (or years) at one hospital and the remaining year (or
years) at another hospital during the first 3 years of the program. In
addition, we are including an example where residents spend partial
years at different hospitals during the first 3 years of the new
residency program:
Example 1
Assume Hospital A has 10 residents in a new internal medicine
residency program. These 10 residents are trained at Hospital A for 2
years of the program. In the third year of the program, 5 of the 10
residents are rotated to Hospital B for training.
Hospital A would receive an adjustment to its cap of 10 FTE (5
residents * 2 years).
Hospital B would receive an adjustment to its cap of 5 FTE (5
residents * 1 year).
Example 2
Assume Hospital A has the following residents training in its new
internal medicine residency program:
Year 1-10 new program year (PGY \1\ 1) residents
Year 2--Hospital A rotates the 10 (now PGY 2) residents from Year 1 to
Hospital B for training for 1 year and Hospital A also accepts 8 (PGY
1) new residents.
Year 3--The 10 (now PGY 3) residents who rotated to Hospital B in Year
2 return to Hospital A. Hospital A accepts 9 new (PGY 2) residents and
also rotates the 8 (PGY 2) residents from Year 2 to Hospital B for
training for 1 year. Thus, in the third year of the program, Hospital A
has 10 (PGY 3) residents and 9 (PGY 1) residents and Hospital B has 8
(PGY 2) residents.
Hospital A would receive an FTE cap adjustment of 20 FTE (10
residents * 2 years).
Hospital B would receive an FTE cap adjustment of 8 FTE (8
residents * 1 year).
\1\ PGY = Program Year
Example 3
Assume Hospital A has 10 residents in a new internal medicine
program for one half of each of the three residency program years.
Hospital B trains the 10 residents for the other half of each of the
three residency years.
Hospital A would receive an FTE cap adjustment of 15 FTEs (10
residents * .5 FTE * 3 years).
Hospital B would receive an FTE cap adjustment of 15 FTEs (10
residents * .5 FTE * 3 years).
Both Hospital A and Hospital B train a total of 5 FTE residents
each residency program year (.5 of 10 residents each year) and this
number is multiplied by the minimum accredited length of the residency
program (3 years for internal medicine).
Comment: One commenter suggested that only the hospital or
hospitals that have received the accreditation for the new residency
program should receive the adjustment to the FTE cap or caps.
Response: While Medicare will provide GME payment to a hospital for
training a resident only if that resident is participating in an
accredited program, it is irrelevant whether the accreditation for the
program belongs to the hospital currently training the residents or
some other entity. Thus, we disagree with the commenter's suggestion to
allow only hospitals that received the new residency program
accreditation to receive a new residency program adjustment.
Comment: Several commenters were concerned about our provision on
the adjustment to the FTE cap during the first 3 years of a new
residency program, as specified in proposed Sec. 413.86(g)(6)(i)(B).
One commenter stated that it seemed inconsistent to refer to
``adjusting the cap'' during these years when the cap is not actually
adjusted until the third year. Another commenter suggested that, when
looking at the number of residents training at the hospital during the
first 3 years for purposes of deciding the cap adjustment in those 3
years, the FTE count for cost reporting purposes should be based on the
number of residents for which the hospital has oversight and the time
worked in locations within or outside the hospital complex to which
they rotate.
Response: Section 413.86(g)(6)(i)(B) contains the provision that
explains how a hospital is to adjust its FTE cap during the first 3
years of establishing a new residency program--the hospital's cap may
be adjusted during each of the first 3 years using the actual number of
residents participating in the new program. The ``number of residents
participating in the new program'' means the number of residents
actually training at that hospital. It does not mean the number of
residents within the ``oversight'' of the hospital, which could include
the time residents spend at other types of facilities during their
training; it only includes the time the residents spend training at the
actual hospital site.
When a hospital establishes a new residency program, the hospital's
1996 FTE cap for the first 3 years is adjusted. Thus, the 1996 FTE cap
is also receiving an adjustment during those 3 years.
Comment: One commenter noted that while we made clarifications in
our new residency program adjustment policy under Secs. 413.86(g)(6)(i)
and 413.86(g)(6)(ii), we failed to make consistent changes to
Sec. 413.86(g)(6)(iii).
Response: We agree that we inadvertently omitted the third change.
We are revising Sec. 413.86(g)(6)(iii) in this final rule.
Comment: One commenter suggested that our meaning is unclear
concerning our provision in proposed redesignated
Sec. 413.86(g)(6)(i)(D) that allows a rural hospital that receives an
adjustment to its FTE cap for establishing new residency programs to
affiliate with other hospitals for the purpose of establishing an
aggregate cap.
[[Page 41521]]
Response: We are revising the language in this section to state
more clearly that, in the case of hospitals in urban areas, we limit
the use of affiliations to provide for aggregate caps only to urban
hospitals that did not receive a new residency program adjustment for a
program begun on or after August 6, 1997 (the date after enactment of
the BBA). Urban hospitals that had no program or programs reported for
their most recent cost reporting period ending on or before December
31, 1996 and have received an FTE cap adjustment for a new program may
not affiliate with other hospitals for purposes of establishing an
aggregate FTE cap. However, rural hospitals that had no program or
programs reported for the most recent cost reporting period ending on
or before December 31, 1996 and have received an FTE cap adjustment for
establishing a new program may affiliate with other hospitals for
purposes of establishing an aggregate FTE cap.
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 proposed 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 were temporarily
trained at another hospital.
Under current policies, if a new medical residency training program
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 would 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
would 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 proposed 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 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 proposed 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 proposed 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 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 but sponsored by the newly constructed hospital 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 based on the
number of residents training in the third year of the first of those
programs begun at the 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.
Comment: With regard to our proposed change concerning our
adjustment to the GME caps for newly constructed hospitals, one
commenter suggested that while Secs. 413.86(g)(7)(i)(A) and (B) appear
to be clear and straightforward, Secs. 413.86(g)(7)(ii) and (iii) are
unclear and add confusion to the calculation of the newly constructed
hospital's FTE cap. The commenter suggested that Secs. 413.86(g)(7)(ii)
and (iii) be removed.
Another commenter suggested that a newly constructed hospital under
Sec. 413.86(g)(7) should be able to affiliate with other hospitals for
purposes of establishing an aggregate FTE cap.
Response: The purpose of both Secs. 413.86(g)(7)(i)(B) and
413.86(g)(7)(ii)(B) is to clarify how to establish the newly
constructed hospital's FTE cap in all possible situations. The
regulation at ' 413.86(g)(7)(i)(B) addresses the calculation of the
newly constructed hospital's FTE cap if the new program has been in
existence for 3 or more years at the temporary training site by the
time the residents begin training at the newly constructed hospital.
The regulation at Sec. 413.86(g)(7)(ii)(B) addresses the calculation of
the cap if the new program has been in existence for 3 or fewer years
at the temporary training site by the time the residents begin training
at the newly constructed hospital.
We agree with the commenter's suggestion to allow a newly
constructed hospital under Sec. 413.86(g)(7) to affiliate for purposes
of establishing an aggregate FTE cap. We currently allow teaching
hospitals that receive a new residency program adjustment under
Sec. 413.86(g)(6)(ii) to affiliate with other hospitals if the teaching
hospitals had established new programs prior to the enactment of the
BBA. Teaching hospitals could not have known what policies would be
enacted in the BBA. Therefore, they would not have had the opportunity
to establish programs for purposes of affiliation in order to
circumvent the FTE cap established by the BBA. The commenter notes that
we used the same rationale when espousing
[[Page 41522]]
the policy on newly constructed hospitals in the proposed rule--we are
allowing hospitals that began construction prior to August 5, 1997 to
establish an FTE cap because the hospitals would not have had knowledge
of the provisions of the BBA. For the same reason, we agree that the
newly constructed hospital should be able to affiliate for purposes of
establishing an aggregate cap because the hospital under construction
would not have known the BBA restrictions. Therefore, we are revising
the text of Sec. 413.86(g)(7) to include this new policy.
In addition, consistent with this reasoning, we are allowing newly
constructed hospitals under Sec. 413.86(g)(7) to calculate their FTE
cap using the same methodology as articulated in Sec. 413.86(g)(6)(ii),
the provision for teaching hospitals that establish new residency
programs on or after January 1, 1995 and on or before August 5, 1997.
We allow those teaching hospitals to receive a new residency program
adjustment during that ``window'' because these hospitals could not
have known what requirements would be enacted in the BBA if the
teaching hospitals established new programs during that time. As stated
above, we used the same rationale for allowing newly constructed
hospitals to establish a cap--these hospitals could not have known
about the BBA when the hospitals established residency programs.
Therefore, we are adding language to Sec. 413.86(g)(7) as follows: `` *
* * a hospital that began construction of its facility on or before
August 5, 1997, sponsored new medical residency training programs that
were established on or after January 1, 1995 and on or before August 5,
1997, and either received initial accreditation by the appropriate
accrediting body or temporarily trained those residents at another
hospital(s) until the facility was completed, may receive an adjustment
to its FTE cap.'' We note that we are clarifying the phrase ``prior to
August 5, 1997'' to mean ``on or before August 5, 1997'' to make it
consistent with this policy. We also are making conforming changes to
Secs. 413.86(g)(7)(i)(A) and (B) and 413.86(g)(7)(ii)(B) to allow the
cap to be adjusted for each new program established within the
``window.'' Under the previous language, the adjustment was tied to the
third year of the first new program. Under the new language, the
adjustment is tied to each new program's establishment during the
``window.'' Therefore, for example, in a situation where a newly
constructed hospital establishes a new residency program and the first
new program began on July 1, 1995, and a second program began on July
1, 1997, the adjustment for the second program under the previous
language would have been tied to the third year of the first new
program (1997). However, under the new language, the adjustment for the
second program is not established until the third year (1999) of the
second program's existence.
Comment: Another commenter suggested that we include the word
``new'' when referring to medical residency training programs in
Sec. 413.86(g)(7)(ii) and (iii).
Response: We are making the revision as the commenter suggests.
This revision will clarify that the provisions allowing an adjustment
to the FTE cap for a facility constructed on or before August 5, 1997
applies to new residency programs.
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. In the May 7, 1999 proposed rule, we proposed to allow
adjustments to address hospital closures after this period. Thus, we
would allow an adjustment for a hospital if it trains 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 proposed this change because hospitals have indicated a
reluctance to accept additional residents from a closed hospital
without a temporary adjustment to their caps. We proposed 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 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.
The hospital must also document that it 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 specify 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).
Comment: Many commenters were generally pleased with our proposed
policy concerning the temporary adjustment to FTE caps to reflect
residents affected by hospital closures specified under proposed
Sec. 413.86(g)(8). However, various commenters asked us to define what
we meant by a ``closed'' hospital.
Response: Section 413.86(g)(8) provides that a hospital may receive
a temporary adjustment to its FTE cap to reflect residents added
because of another hospital's closure which occurs on or after July 1,
1996. By hospital ``closure,'' we mean the hospital terminates its
Medicare participation agreement with HCFA under the provisions
specified in Sec. 489.52. To ``close,'' a hospital would have to comply
with the requirements as specified in this section to terminate its
agreement. We are making conforming changes in Sec. 413.86(g)(8) on the
temporary adjustment to reference Sec. 489.52.
Comment: Many of the commenters suggested that we include
bankruptcy of a hospital and lost accreditation of a program, both acts
that displace residents, as applicable to the temporary adjustment
policy.
Response: We do not agree with the commenters. We do not believe it
is appropriate to expand our policy to cover any acts other than
hospital
[[Page 41523]]
closure because, unless the hospital actually terminates its Medicare
agreement, it will retain its statutory FTE cap. For example, in the
case where a hospital files for bankruptcy, it continues to retain its
FTE cap. While the bankruptcy action may displace the hospital's
residents, the hospital continues to be subject to the statutorily
mandated cap on FTEs. Therefore, it can still decide to train residents
at the hospital or affiliate with other hospitals for purposes of
establishing an aggregate cap. The hospital may, in fact, use its
ability to affiliate in order to place its residents at a new hospital.
Comment: One commenter explained that there were hospitals that had
plans to close their doors earlier this year and deliberately remained
open for various reasons until the start of the July 1, 1999 residency
year. This commenter suggested that because hospitals are training
these displaced residents beginning on July 1, 1999, we should change
the effective date of the temporary adjustment provision to coincide
with the July 1, 1999 date. Similarly, another commenter was concerned
about affiliated groups, suggesting that because final regulations on
affiliated groups were not published until May 12, 1998, some hospitals
that would have liked to have participated in affiliations prior to the
FY 1998 were not able to because there were no implementing regulations
before the May 12, 1998 date.
Response: The effective date of the temporary adjustment policy,
like the effective date for all changes in this final rule, is October
1, 1999.
Similarly, hospitals that choose to affiliate cannot do so before
the effective date of the May 12, 1998 regulation.
Comment: Under the temporary adjustment provision,
Sec. 413.86(g)(8)(ii) requires a hospital to submit a request for the
temporary adjustment to its fiscal intermediary at least 60 days before
the hospital begins to train the residents. One commenter suggested
that it was not appropriate for the fiscal intermediary to be in the
position of granting requests for adjustments. In addition, several
commenters suggested that submitting a request at least 60 days before
the hospital begins to train the residents is ``problematic,'' since it
is not always easy to estimate exactly when a hospital will close and
other hospitals can then continue training the residents.
Response: The fiscal intermediaries have been delegated the
authority to calculate Medicare program payments for hospitals,
including GME payments. HCFA is not in a position to be able to respond
to every request for a temporary FTE cap adjustment. As long as
hospitals that request the adjustments meet each condition in our
regulations, the hospitals will receive the adjustments.
We agree with the commenters who suggested that requiring a
hospital to submit a request for a temporary adjustment to an
intermediary at least 60 days before the hospital begins to train the
residents might be problematic for hospitals. Therefore, we are
revising our regulations to require a hospital to submit a request for
a temporary adjustment to an intermediary no later than 60 days after
the hospital first begins training the displaced residents.
Comment: One commenter requested that we clarify the provision at '
413.86(g)(8)(ii) that hospitals must identify residents that come from
closed programs in order to receive a temporary adjustment to their FTE
caps.
Response: In order to receive a temporary adjustment to their FTE
caps, hospitals must provide the social security numbers of the
residents coming from the closed hospital and documentation that proves
that the residents were training at the hospital that closed.
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 proposed 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 proposed 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.
Comment: At Sec. 413.86(g)(1), we proposed to update the provisions
concerning what source to use when calculating the initial residency
period for residencies. One commenter stated that one of the provisions
that we updated, changing ``1985-1986 Directory of Residency Training''
to ``the most recently published edition of the Graduate Medical
Education Directory,'' applies only when calculating the initial
residency periods for allopathic residencies. The commenter suggests
that initial residency periods for all residencies be published in the
Federal Register. The commenter further suggested that, for determining
the updates of initial residency periods for dental residencies, the
most recent accreditation standards of the Commission on Dental
Accreditation for advanced dental programs be used. Another commenter
asked whether the most recently published edition of the Graduate
Medical Education Directory or the initial residency periods is
published in the Federal Register should be the guiding source when
calculating the initial residency periods for residencies in the case
where there is a discrepancy between the two.
Response: Generally, proposed redesignated Sec. 413.86(g)(1)(i)
defines the initial residency period as ``the minimum 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.'' Proposed Sec. 413.86(g)(1)(ii)
provided that for residency programs in osteopathy, dentistry, and
podiatry, ``the minimum number of years of formal training necessary to
satisfy the requirements of the appropriate approving body listed in
Sec. 412.152 of this chapter.'' Section 412.152 lists all of the
accreditation organizations for allopathy, osteopathy, podiatry, and
dentistry, including the Commission on Dental Accreditation of the
American Dental Association. In other words, while the Graduate Medical
Education Directory only applies to allopathic residencies, as the
first commenter suggests, the organization that the commenter
encourages us to use as the accrediting organization for purposes of
determining the initial residency period for dental residencies--the
Commission on Dental Accreditation of the American Dental Association--
is already used to determine the initial residency periods for dental
residencies.
[[Page 41524]]
The first commenter also suggests that we publish the initial
residency periods in the Federal Register. While we have already done
so in the August 30, 1996 Federal Register (61 FR 46208), we plan to
update the list of initial residency periods in upcoming regulations.
The second commenter asked for guidance in the case where the initial
residency periods listed in the August 30, 1996 (and in future
regulations) differ from the information listed in the most recent
edition of the Graduate Medical Directory. The information that we used
to publish the initial residency periods in the August 30, 1996 Federal
Register is based on the most recent edition of the Graduate Medical
Directory. The Graduate Medical Directory is the most current and
updated source of information on allopathic residencies. We agree that
in some cases our latest listing in the Federal Register may not
reflect the most recent update of the applicable directory. Thus, in
the case where there is a discrepancy in the length of an initial
residency period listed in what we publish in the Federal Register and
what is published in the most recent edition of the Graduate Medical
Education Directory (or other applicable publications for the other
specialty areas), the Directory should be the guiding source.
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.
Comment: Several commenters requested that we clarify that a
nonteaching hospital that participates in an affiliated group agreement
as specified under Sec. 413.86(g)(4) is not precluded from later
seeking an adjustment to its FTE cap for establishing a new residency
program.
Response: We agree with the commenters' request. Consistent with
our regulations at Sec. 413.86(g)(6)(i), a nonteaching hospital that
participated (or participates) in an affiliated group for purposes of
establishing an aggregate FTE cap does not forego its opportunities to
later establish new residency programs and accordingly receive an
adjustment to its individual FTE cap. The requirements under
Sec. 413.86(g)(6)(i) specify that a hospital may receive an adjustment
to its FTE cap for establishing a new residency program if the hospital
had no allopathic or osteopathic residents in its most recent cost
reporting period ending on or before December 31, 1996. In other words,
the hospital must have a zero FTE cap based on its number of residents
in its most recent cost reporting period ending on or before December
31, 1996 in order to qualify to receive an adjustment under this
provision. The fact that a nonteaching hospital has affiliated with
other hospitals does not change the fact that in determining the
aggregate cap for the affiliated group the nonteaching hospital still
has an FTE cap of zero. Accordingly, consistent with our regulations, a
nonteaching hospital that affiliates is not precluded from later
seeking a new residency program adjustment.
Comment: The BBA specifically required the Secretary to give
special consideration to facilities that meet the needs of underserved
rural areas. With this mandate in mind, several commenters requested
that we consider recognizing new family practice programs that are
classified as rural by the Residency Review Committee for the purpose
of establishing a cap and receiving GME payment under Medicare.
Response: We will consider the suggestion to apply our rules for
rural hospitals to all hospitals with the new family practice programs
for purposes of GME in developing future regulations.
Comment: We received several other comments suggesting GME policy
changes concerning rural hospitals. One commenter suggested that we
allow rural hospitals that received a new residency program adjustment
under Sec. 413.86(g)(6)(ii) to affiliate with other hospitals for
purposes of establishing an aggregate FTE cap. Another commenter
suggested that we allow rural hospitals a new residency program
adjustment for expansions of already established residency programs at
the rural hospitals.
Response: Any hospital, rural or urban, that receives a new
residency program adjustment under Sec. 413.86(g)(6)(ii) is permitted
to affiliate for purposes of establishing an aggregate cap. As for
allowing an FTE cap adjustment for expansions of already established
residency programs at rural hospitals, we will take this policy
suggestion into consideration in future regulations.
Comment: We received many comments on various other GME issues. One
commenter asked what level of documentation is needed to demonstrate
for purposes of our nonhospital payment policy that a particular
hospital and nonhospital site are a single legal entity. Another
commenter asked for a cost report change to account for situations when
a hospital could have one FTE cap for one-half of the year and a
different cap for the second half of the year. One commenter suggested
that, in a situation when two hospitals affiliate for purposes of
establishing an aggregate cap, the hospital that is the sponsor of the
residency program should be given the ability to better control the
limited number of training slots as established under the aggregate
cap. Another commenter suggested that we consider allowing a new
residency program adjustment for family practice programs beginning on
or after July 1, 1994. Finally, one commenter made two suggestions: (1)
that we increase a particular hospital's FTE count because when the cap
was set, some of the hospital's residents were rotated out to other
hospitals to meet a Residency Review Committee (RRC) program
requirement, and are now brought back into the hospital after the BBA
because the hospital can now meet the RRC requirement, and (2) that we
allow payment to a hospital that had established an ambulatory care
rotation prior to the BBA.
Response: We will consider all of these suggestions made by the
commenters in future regulations.
Comment: One commenter suggested that we discuss what happens to
hospitals' FTE caps in situations where there is a merger of two or
more hospitals.
Response: We discussed the merger of hospitals and FTE caps in the
May 12, 1998 Federal Register (63 FR 26329). Where two or more
hospitals merge after each hospital's cost reporting period ending
during FY 1996, the merged hospital's FTE cap will be an aggregation of
the FTE cap for each hospital participating in the merger.
V. 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
[[Page 41525]]
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 the 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 are 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 a base
year hospital-specific rate lower than the Federal rate is 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 is 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 as of December 31, 1990, but put in use for
patient care after December 31, 1990, also may 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
the vast majority of hospitals.
In the August 30, 1991 final rule, we also established a capital
exceptions policy, which provides for exceptions payments during the
transition period (' 412.348). Section 412.348 provides that, during
the transition period, a hospital may receive additional payment under
an exceptions process when its regular payments are less than a minimum
percentage, established by class of hospital, of the hospital's
reasonable capital-related costs. The amount of the exceptions payment
is the difference between the hospital's minimum payment level and the
payments the hospital would receive under the capital prospective
payment system in the absence of an exceptions payment. The comparison
is made on a cumulative basis for all cost reporting periods during
which the hospital is subject to the capital prospective payment
transition rules. The minimum payment percentages for regular capital
exceptions payments by class of hospitals for FY 2000 are:
For sole community hospitals, 90 percent;
For urban hospitals with at least 100 beds that have a
disproportionate share patient percentage of at least 20.2 percent or
that received more than 30 percent of their net inpatient care revenues
from State or local governments for indigent care, 80 percent;
For all other hospitals, 70 percent of the hospital's
reasonable inpatient capital-related costs.
We 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.
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 as described at
Sec. 412.348(g)(2), which, in the case of certain urban hospitals,
includes an excess capacity test; and (2) a project size requirement as
described at Sec. 412.348(g)(5). Eligible hospitals include sole
community hospitals, urban hospitals with at least 100 beds that have a
disproportionate share percentage of at least 20.2 percent, and
hospitals with a combined Medicare and Medicaid inpatient utilization
of at least 70 percent. 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).
For hospitals in States with certificate of need (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.
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), generally, if a project is
completed by September 30, 2001, exceptions payments could continue up
to September 30, 2011. In addition, we believe that for projects
completed after the September 30, 2001 deadline, 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
[[Page 41526]]
payments so we could determine if any changes in the special exceptions
criteria or process were necessary.
In the May 7, 1999 proposed rule (64 FR 24736), we reported that
four hospitals had responded timely to our solicitation with
information on their major capital construction projects. The hospitals
submitted information about their location, the cost of the project,
the date that the CON approval was received, the start date of the
project, and the anticipated completion date.
The hospitals suggested changing a number of the requirements of
the special exception provision, including (1) changing the project
completion date requirement; (2) revising the project size requirement;
(3) lowering the DSH qualifying percentage from 20.2 percent to 15
percent; (4) changing the minimum payment level from 70 percent to 85
percent; and (5) revising the qualifying criteria so that only capital
payment margins are considered instead of both capital payment margins
and operating margins (as is now the case). In addition, hospitals
suggested capping special exceptions payments that result from changes
to the special exceptions process at $40 million annually.
When we issued the May 7, 1999 proposed rule, we had no specific
proposal to revise the special exceptions process. However, we invited
comments from hospitals and other interested parties on the suggestions
and recommendations discussed above. We noted 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. That is, 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 also noted that,
based on the comments we received, we may make changes to the special
exceptions criteria in the final regulation or propose changes in the
FY 2001 proposed rule.
In the May 7, 1999 proposed rule, we indicated that we had little
information about the impact of any of the suggested changes discussed
in the proposed rule, since no hospitals are currently being paid under
the special exceptions process. Until FY 2001, the special exceptions
provision currently pays either the same as the regular exceptions
process or less for high DSH and sole community hospitals. We indicated
that we would attempt to obtain information on projects that might
qualify for special exceptions payments through our fiscal
intermediaries during the comment period. However, we noted that we
were reluctant to impose a burden on the fiscal intermediaries at this
time, since it could interfere with our major efforts to make the
Medicare computer systems Y2K compliant prior to January 1, 2000.
We received six comments on potential changes to the special
exceptions process. Three were in favor of changing the process in
various ways, and two were opposed to making any changes. In addition,
MedPAC opposed expanding the process until we have a better estimate of
the impact of any expansion.
Comments: Three commenters that supported changing the special
exception process made various suggestions as to what those changes
should be.
Two of the commenters believe that the way HCFA formulated the
special exceptions process is inconsistent with Congressional intent
because the Conference Report that accompanied the Omnibus Budget
Reconciliation Act (OBRA) of 1993 (Public Law 103-66) indicated the
conferees' expectation that HCFA would assess information and make
appropriate changes to ``. . . address the problems of hospitals
subject to lengthy CON review processes or subject to other
circumstances which are not fully addressed in the current rules''
(H.R. Rep. No. 103-213, at 744 (1993)). The commenters noted that
Congress used a separate sentence to state a belief that 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.'' Thus, the commenters
believe that Congress did not intend to limit the special exceptions
process to any particular type of hospital and that Congress intended
HCFA to deal separately with the problems of high DSH hospitals and to
make the special exceptions process available to all hospitals.
One commenter stated that eligibility for special exceptions
payments should be based solely on when a hospital had to begin a
capital project and the size of the project, rather than ``noncapital-
related'' tests such as the operating offset and the DSH requirement.
The commenter argued that, if the purpose of the special exceptions
process was to help hospitals that could not benefit from old and
obligated capital provisions, then HCFA did not act consistently with
that premise when it adopted criteria that limited qualifying
hospitals. The commenter believes that HCFA may have adopted some
criteria, such as the requirement that urban hospitals must have a DSH
percentage of at least 20.2 and the offset of positive operating
margins, to limit the cost of the special exceptions program. If that
is the case, then the commenter suggested that a cap on total payments
made under the special exceptions authority would accomplish the same
result more fairly.
One commenter requested that the DSH percentage requirement for
urban hospitals (20.2 percent) be lowered. The commenter believes that
the current requirement is not a natural result of the rationale we
used for limiting the special exceptions process, and that, if a
hospital builds a project during the transition, it is disadvantaged
relative to other hospitals regardless of its DSH percentage. This
commenter suggested that, if we do decide to retain the DSH
requirement, the requirement be lowered to 15 percent, and that we
adopt a sliding scale payment floor of between 15 and 20.2 DSH
percentages in which the minimum payment level at the 15 DSH percentage
would be 70 percent and the maximum payment level at 20.2 DSH
percentage would be 85 percent.
One commenter supported lowering the project size requirement from
100 percent of the hospital's FY 1992 operating costs to 45 percent of
those costs.
All three commenters who advocated changes to the special
exceptions process supported changing the offset provision so that
eligibility for special exceptions does not take into account positive
operating margins. They argued that the operating and capital payment
methodologies were separately developed and that payments are
separately calculated. If the offset against operating payments is not
eliminated, they believe it should be modified to include outpatient
margins as well. One of these commenters noted that a similar offset
was not required for ``old capital.''
Two of the commenters recommended that, if a hospital had received
CON approval by September 1, 1995 and expended $750,000 or 10 percent
of total project cost, then the project completion date should be
extended to December 31, 2003. They believe that a hospital could have
started planning a major capital project early in the transition, but,
because of events beyond the hospital's control, the completion date
might extend beyond the end of the transition.
[[Page 41527]]
Two commenters suggested that we should establish a cap on special
exceptions payments, and indicated that HCFA has the authority to set
and implement such a cap because of the authority given the Secretary
under section 1886(g) of the Act to implement the capital prospective
payment system. The legislation provided for an exceptions process, as
the Secretary determined to be appropriate. The commenter asserted that
the ``regular'' capital exceptions process already includes a ``cap''
of 10 percent. The commenters recommended a cap of 1 percent of total
capital prospective payments in a given fiscal year, and that, if
aggregate eligibility for payments exceeds the cap, the payments would
be reduced on a pro rata basis.
The commenters also recommended that any exception payments a
hospital qualifies for but does not receive because of the cap should
be rolled over into future years so that those payments could be made
in later years. Without a rollover provision, the commenters advocate
setting the cap at 1.5 percent. They believe that with the expiration
of hold harmless provisions and the exceptions floors in FY 2001, the
suggested cap would result in lower budget neutrality adjustments than
is currently the case.
Using 1992 through 1996 cost report data, one of the commenters
prepared an estimate of the number of hospitals it believes will be
eligible for special exception payments if the criteria were changed as
suggested by the commenter. Based on the commenter's estimate,
aggregate eligibility for special exceptions payments would exceed the
recommended 1 percent cap for approximately 5 years (FY 2002 through FY
2006). The commenter also suggested that hospitals that believe they
are eligible for special exceptions be required to submit an
application to their fiscal intermediary in January of each year, and
to update their application by June of each year, so that an estimate
could be prepared of the number of hospitals that will qualify for
special exceptions. The data could also be used to estimate the amount
of reductions that will be required to stay within the cap. The
commenter suggests that hospitals that did not submit the information
could be precluded from receiving special exceptions payments in the
following fiscal year.
All three commenters who advocated changes to the special
exceptions process supported raising the 70 percent minimum payment
level to 85 percent. One commenter objected to the 70 percent minimum
payment level, arguing that it offers little improvement over the
Federal rate and guarantees that hospitals will take a 30-percent loss
on their actual capital costs for each Medicare discharge. This
commenter believes that special exceptions should be paid at the rate
of 85 percent, which is what hospitals eligible for old capital hold
harmless payment received.
In addition, two of the commenters supported finalizing changes to
the special exceptions process in the FY 2000 final rule so that
affected hospitals can plan more effectively.
Two national hospital associations were opposed to changing the
special exceptions policy. They believe that the special exceptions
process was intended to be limited in scope, and although some
hospitals may be disadvantaged by some aspects of the fully Federal
capital prospective payment system, they have had a number of years to
plan for it. All other hospitals will be receiving payments based on
the Federal rate beginning in FY 2002 and the commenters do not believe
that the majority of hospitals should have their payments further
reduced to expand the special exceptions process to a few hospitals.
One of the commenters noted that Congress considered a similar proposal
to expand the special exceptions process as part of the BBA
deliberations and, ultimately, did not include the proposal. The
commenter believes this failure to act was an indication of
Congressional intent, and that HCFA has no authority to disregard it
and adopt these changes by regulation. The other commenter stated that
since HCFA has no reliable estimate of the number of hospitals that
would be affected by changes to the special exceptions process, it
would be capricious to make a change absent an impact analysis.
Response: When we proposed the special exceptions process in 1994
(May 27, 1994, Federal Register (59 FR 27746)), we stated ``* * * we
are therefore proposing at Sec. 412.348 to provide special protection
for some hospitals that are undertaking major projects to renovate or
replace aging plant during the transition period. This special
protection, which will provide a 70 percent minimum payment level for
up to 10 years beyond the transition period, will be available only to
* * * [s]ole community hospitals * * *; [u]rban hospitals with at least
100 beds that either have a DSH percentage of 20.2 percent or receive
at least 30 percent of their revenue from State or local funds for
indigent care * * *; [h]ospitals with a combined inpatient Medicare and
Medicaid utilization of at least 70 percent. * * *'' We believe this
strict set of qualifying criteria makes it clear that we intended to
make the special exception process limited in scope.
Since publication of the proposed rule, we have attempted to obtain
information on hospital projects that might qualify for special
exceptions payments in order to assess the impact of the recommended
changes to the existing policy. Because of the impracticality of
obtaining data timely from every State in the country, we focused our
efforts on certain States. Using information obtained from the
Department of Housing and Urban Development (HUD) and the Health
Resources and Services Administration (HRSA), we developed a list of
States in which a large concentration of hospital construction occurred
during the capital transition period. For several States, we contacted
the State Department of Health's Facility and Planning Staff, who
provided us with information on the hospital construction projects in
their State, including the name and location of the hospital, the cost
of the construction project, the date of CON approval (if required),
the start date of the project, and the completion or anticipated
completion date of the project. In conjunction with the most recent
cost report data readily available (FY 1996), we attempted to estimate
which of the hospital construction projects might qualify for special
exception payments under the existing policy and how that universe of
hospitals might change as a result of the recommended revisions to the
special exceptions criteria.
Because exception payments to a hospital for a given cost reporting
period are based on a percentage of the hospital's capital costs
incurred during the cost reporting period, we were unable to determine
a precise estimate of the amount of payments to hospitals that might be
eligible for special exceptions. In addition, hospitals are not
eligible for special exception payments until the assets are put into
use for patient care. Once eligibility for special exceptions payment
has been demonstrated, it is some time before completed and settled
cost reports are available to determine these payments. It is also
difficult to predict whether particular hospitals will be able to meet
all of the special exceptions eligibility criteria (DSH percentage,
inpatient margins, completion date, project size, and project need
requirements) in future years based on the earlier cost report data.
Based on our research, we were able to identify a universe of 266
possible hospital construction projects from two States (New York and
Illinois) that
[[Page 41528]]
might possibly qualify for special exception payments. Our data largely
understate the total number of eligible projects that may qualify for
special exception payments nationally since our estimate is based on
data from only 2 of the 50 States in the country. Our estimate includes
all inpatient hospital construction projects in those two States, of
which only a subset of projects will qualify for special exception
payments. Extrapolating our estimate to the large numbers of hospital
construction projects nationally, we believe that any changes to the
special exceptions policy may affect a significant number of hospitals.
Based on our belief that these changes may have an impact on a
significant number of hospitals and our evaluation of the comments and
after careful consideration of all the issues, we have concluded, as
suggested by one commenter, that the more appropriate forum for
addressing the capital special exception is the legislative process in
Congress rather than the regulation process.
Based on this conclusion, we are generally not addressing the
specific changes recommended for the special exceptions process or
eligibility criteria. However, there are some comments on the general
policies of the special exception process that we would like to address
individually. These include our efforts to address the OBRA 1993
Conference Report language concerning the obligated capital provisions
of the capital prospective payment system, the rationale for the 70
percent minimum payment level for the special exceptions process, and
the administrative feasibility of capping special exception payments
and rolling over unfunded special exceptions to future years.
First, in the Conference Report that accompanied OBRA 1993,
Congress addressed obligated capital criteria for hospitals in States
with a lengthy 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 rule (59 FR 27744), we described our
analysis of provisions related to obligated capital for hospitals
subject to lengthy CON processes. We also proposed a change to the
deadline for putting an asset into use for patient care
(Sec. 412.302(c)(2)(i)(D)) and addressed recommendations that we had
received from hospitals to change 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.
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) 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. We also implemented the capital special exceptions process
and expanded the qualifying criteria for the classes of eligible
hospitals to include sole community hospitals; urban hospitals with at
least 100 beds that have a DSH percentage of at least 20.2 percent or
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.
Because we adopted changes to both the obligated capital criteria
and finalized the special exceptions process, we believe that we have
appropriately addressed the issues raised in the Conference Report
language concerning hospitals in States with a lengthy CON process as
well as SCHs and hospitals that serve a disproportionate share of low-
income patients.
Second, in response to the commenters' suggestion that the 70
percent minimum payment level for special exceptions be raised to 85
percent, we believe that this change would expand the special
exceptions process beyond its original narrow focus. The commenters'
comparison of the special exceptions process to hold harmless payments
for old capital is not appropriate. Paying hospitals for 85 percent of
the cost of old capital was reasonable to account for the change from a
cost-based system to a prospective payment system for capital. Since
hospitals had committed to these costs years prior to the
implementation of the capital prospective payment system, it was
reasonable to allow relief to hospitals for these costs. In addition,
during the prospective payment system transition, all hospitals, based
on their costs, were eligible for exception payments to account for
high costs that exceed the prospective payment rate. Except for sole
community hospitals and hospitals with a DSH percentage of at least
20.2, hospitals received exceptions payments at the 70-percent minimum
payment level. A 70-percent minimum payment level for special
exceptions continues exceptions payments for qualifying hospitals with
high costs after the transition at the same level most hospitals
received under the regular exceptions process during the transition.
Third, it would be extremely difficult administratively to
implement a cap and roll-over provision such as the one advocated by
the commenters. Hospitals are not eligible for special exception
payments until assets are put into use for patient care. A lag time
exists before completed and settled cost reports are available to
determine special exception payments once eligibility has been
demonstrated. Information taken from cost reports cannot be used to
accurately determine whether a hospital meets all of the special
exceptions eligibility criteria. Specifically, date of CON approval (if
applicable) and DSH percent are not determined based on cost report
information. Other criteria, such as project size and age of asset (if
applicable) requirements, and their accuracy will need to be reported
by the hospital and verified by the fiscal intermediaries.
Even when we have a more accurate assessment of qualifying special
exception projects, we do not believe a cap and roll-over process such
as the commenter suggests would be administratively feasible. We intend
to administer the existing special exception process in the post-
transition period in a manner similar to the regular exception process.
Based on data received, we will make an estimate of special exception
payments in the
[[Page 41529]]
coming year. If our model shows that special exception payments are
projected to be more than 10 percent of total capital payments under
the existing 70 percent payment level, we would reduce the minimum
payment level to ensure that projected payments do not exceed the 10
percent threshold. If, however, when cost reports were settled for that
fiscal year, payments for eligible projects were determined to be more
or less than the amount estimated, they would still be eligible for
special exception payments, even if actual payments exceeded the amount
we initially estimated. Each year's exception payments are determined
separately. It would be extremely difficult to maintain an estimate of
actual qualifying projects, given varied dates on which hospitals'
fiscal years end, and increase or decrease the exception payment amount
each hospital was eligible to receive. We would not know whether the
amount budgeted for a project was more or less than the amount the
project actually qualified for until the cost report was settled. Since
hospitals have different cost report ending dates, it would be some
time before all the cost reports for a given fiscal year would be
finalized. At that time, it would be necessary for each fiscal
intermediary to determine how much was actually paid for special
exception, and any carryover amount for each project to a future fiscal
year. We believe that this process would be very cumbersome, if not
impossible, to administer.
It is our intention in the FY 2001 proposed and final rules to
discuss a data collection effort to assist us in modeling special
exception payments for the FY 2002 proposed rule.
Comment: MedPAC commented that they share HCFA's desire to keep
special exceptions narrowly targeted. The Commission stated that many
of the suggestions for changing the special exception process and
criteria would unnecessarily expand payments beyond clearly
disadvantaged hospitals whose financial health is important to
maintaining access to care for Medicare beneficiaries. MedPAC
recommends that, since so few hospitals responded to our request for
information on potentially qualifying projects, we should not change
the current special exceptions policy until we receive more information
about the extent of financial problems hospitals are having. However,
MedPAC does believe that we should consider increasing the special
exceptions payment for SCHs and urban hospitals with a DSH percentage
of at least 20.2 percent to equal the amount they receive under the
regular exceptions policy (that is, 90 and 80 percent, respectively).
MedPAC suggests that these increases are necessary to continue to
provide financial protection to institutions that safeguard access to
care for Medicare beneficiaries.
MedPAC supports offsetting special exceptions payments against both
capital and operating margins, because it is consistent with their
belief that at the end of the transition the two payment systems should
be combined.
Response: We agree with MedPAC that, in determining eligibility for
special exception payments, it is appropriate to examine a hospital's
operating margins as well as its capital margins. We believe it is
reasonable to provide an additional limit on exceptions payments for
the period 10 to 20 years after the beginning of capital prospective
payments. In addition, we agree that since inpatient operating and
capital costs are so inherently intertwined in providing inpatient
care, it is appropriate to have an operating payment offset for the
capital special exception. It is not appropriate to consider any
outpatient services when determining eligibility for the inpatient
special exception payment. Any outpatient capital-related costs are
paid to hospitals under Medicare Part B.
VI. 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), (c), (f), 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 on
existing facilities, 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. Under section 1886(b)(3)(H)(iii) of the
Act, the resulting amounts are updated by the market basket percentage
increase applicable to the fiscal year.
In the May 7, 1999 proposed rule, we proposed the following caps on
target amounts for cost reporting periods beginning in FY 2000:
Psychiatric hospitals and units: $11,067
Rehabilitation hospitals and units: $20,071
Long-term care hospitals: $39,596
These proposed caps reflected an update of 2.6 percent, the projected
market basket increase for excluded hospitals and units.
The final projection of the market basket percentage increase for
excluded hospitals and units for FY 2000, based on the most recent data
available, is 2.9 percent. Accordingly, the final caps on the target
amounts for existing hospitals and units for cost reporting periods
beginning during FY 2000 are as follows:
Psychiatric hospitals and units: $11,100
Rehabilitation hospitals and units: $20,129
Long-term care hospitals: $39,712
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 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 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 based on the final FY 1999
figures updated by the projected market basket increase of 2.9
[[Page 41530]]
percent. (The proposed amounts were based on an 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................................... $ 6,394 $ 2,544
Rehabilitation................................ 12,574 4,999
Long-term Care................................ 16,206 6,443
------------------------------------------------------------------------
As specified at Sec. 413.40(c)(4), for purposes of determining the
hospital's target amount for the hospital's third 12-month cost
reporting period, the target amount for the preceding cost reporting
period is equal to the payment amount in the second 12-month cost
reporting period as determined in accordance with
Sec. 413.40(f)(2)(ii)(A). The payment amount 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. It has come to our attention that
Sec. 413.40(c)(4)(v) does not specify how to apply the update factors
to the amount of payment for the second 12-month cost reporting period
in order to calculate the target amount in subsequent cost reporting
periods. Therefore, we are revising Secs. 413.40(c)(4)(v) and
413.40(f)(2)(ii)(A) to clarify the application of the update factors
and the base period for new psychiatric hospitals and units,
rehabilitation hospitals and units, and long-term care hospitals.
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. If the new hospital is a children's hospital, a 2-year exemption
from the application of the target amount is permitted
(Sec. 413.40(f)(2)(i)). A new psychiatric or rehabilitation hospital or
unit or a long-term care hospital receives, for the first two 12-month
cost reporting periods, 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 its becoming part of the multicampus
hospital, would again be applicable. This is consistent with our
current policy for a hospital or unit that is excluded from the
prospective payment system and 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. We proposed 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 hospital or unit
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.
We did not receive any comments on this proposed revision.
Therefore, we are adopting the proposed change to
Sec. 413.40(b)(1)(iii) as final.
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
[[Page 41531]]
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, are based on a comparison of the
hospital's operating costs and its costs used to calculate the FY 1998
rebased target amount. 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 such
items as costs, utilization, and length-of-stay should be 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.
In the proposed rule, we proposed to revise Sec. 413.40(g)(1) to
clarify these limitations on the adjustment payments.
We received no comments on this clarification and, therefore, are
adopting it in this final rule.
4. Report on Adjustment Payments to the Ceiling (Sec. 413.40(g))
Changes in the types of patients served or inpatient care services
that distort the comparability of a cost reporting period to the base
year are grounds for requesting an adjustment payment in accordance
with section 1886(b)(4) of the Act. Section 4419(b) of the BBA of 1997
requires the Secretary to publish annually in the Federal Register a
report describing the total amount of adjustment (exception) payments
made to excluded hospitals and units, by reason of section 1886(b)(4)
of the Act, during the previous fiscal year. However, the data on
adjustment payments made during the previous fiscal year are not
available in time to publish a report describing the total amount of
adjustment payments made to all excluded hospitals and units in the
subsequent year's final rule published in the Federal Register.
The process of requesting, adjudicating, and awarding an adjustment
payment for a given cost reporting period occurs over a 2-year period
or longer. An excluded hospital or unit must first file its cost report
for the previous fiscal year with its intermediary within 5 months
after the close of the previous fiscal year. The fiscal intermediary
then reviews the cost report and issues a Notice of Program
Reimbursement (NPR) in approximately 2 months. If the hospital's
operating costs are in excess of the ceiling, the hospital may file a
request for an adjustment payment within 6 months from the date of the
NPR. The intermediary, or HCFA, depending on the type of adjustment
requested, then reviews the request and determines if an adjustment
payment is warranted. Therefore, it is not possible to provide data in
a final rule on adjustments granted for cost reports ending in the
previous Federal fiscal year, since those adjustments have not even
been requested by that time. However, in an attempt to provide
interested parties at least some relevant data on adjustments, we are
publishing data on requests for adjustments that were processed by the
fiscal intermediaries or HCFA during the previous Federal fiscal year.
The table below includes the most recent data available from the
fiscal intermediaries and HCFA on adjustment payments that were
adjudicated during FY 1998. By definition these were for cost reporting
periods ending in years prior to FY 1998. The total adjustment payments
awarded to excluded hospitals and units during FY 1998 are $95,676,720.
The table depicts for each class of hospital, in aggregate, the number
of adjustment requests adjudicated, the excess operating cost over the
ceiling, and the amount of the adjustment payment.
------------------------------------------------------------------------
Excess cost Adjustment
Class of hospital Number over ceiling Payment
------------------------------------------------------------------------
Psychiatric.................... 235 $112,437,640 $55,784,497
Rehabilitation................. 93 67,353,452 26,487,095
Long-term care................. 7 10,326,069 6,085,941
Children's..................... 7 6,893,393 2,898,679
Cancer......................... 3 10,463,245 4,420,508
------------------------------------------------------------------------
5. 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 that
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 (Sec. 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 hospital inpatient prospective
payment system and were intended to simplify administration of the
exclusion provisions of the prospective payment system by establishing
clear rules for the timing of changes in these excluded units. The
statutory basis and rationale for these rules are explained more fully
in the preamble to the proposed rule (64 FR 24740).
To provide more flexibility to hospitals while not recognizing
changes that undermine statutory requirements and principles, we
proposed to revise Sec. 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
[[Page 41532]]
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 noted 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 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 medical
education and hospitals that serve 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 hospital-based
provider, such as a distinct-part skilled nursing facility, they would
not be counted as part of the hospital paid under the prospective
payment system.
We received six comments on our proposal.
Comment: Several commenters expressed support for the proposed
change and indicated that it would increase hospital flexibility. No
commenters opposed the change. However, one commenter noted that some
California hospitals may need to temporarily vacate certain facilities
to allow renovation and construction necessary to comply with new State
seismic code requirements, and stated that such a relocation of a
facility may necessitate a change in its number of beds or square
footage. The commenter recommended that our regulations be revised to
account for this possibility or for relocations that are necessary due
to catastrophic occurrences such as earthquakes, floods, tornadoes, or
other natural disasters.
Response: We appreciate the commenters' support of our proposal and
are adopting it as final with one change. To address the types of
compliance or catastrophic situations described by one of the
commenters, we are revising Sec. 412.25(b) to allow reductions in the
number of beds in an excluded unit, or increases or decreases in the
square footage of the excluded unit, if these changes result from
relocation of the unit made necessary because of construction or
renovation needed to bring a facility into compliance with changes in
Federal, State, or local law affecting the physical facility, or
because of catastrophic events such as fires, floods, earthquakes, or
tornadoes. We understand that these relocations may necessitate a
change in the square footage of a unit, although it is not clear that
any increase in bed size would be required. We also are allowing
corresponding exceptions to the requirements that a grandfathered
satellite facility be operated under the same terms and conditions in
effect on September 30, 1999 under Secs. 412.23(h)(3) and
412.25(e)(3)).
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 Parts 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 the 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.'' 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.
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.
In the preamble to the proposed rule, we explained in detail our
reason for concern that satellite arrangements could lead to
circumvention of several Medicare payment provisions. To prevent
inappropriate Medicare payment for services furnished in satellite
facilities, we proposed 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 proposed to define a
``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. We proposed that, 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 in the
proposed rule, we reasoned that, if the satellite facility is
effectively ``part of'' the prospective payment system hospital, then
it should be paid under the prospective payment system.
We proposed that 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
proposed to examine the discharges of the satellite facility and to
apply the target amount for the excluded hospital in which the hospital
is located, subject to the
[[Page 41533]]
applicable cap for the hospital of which the satellite is a part. Also,
when the satellite facility is established, we proposed to treat it 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 believed that the proposed
application of the cap for new hospitals was appropriate because we
believe that a number of hospitals are attempting to avoid the hospital
caps by characterizing entities as satellites rather than new
hospitals.
Under the proposed rule, 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 proposed to make this exception
available only to those facilities that could document to the HCFA
regional offices that they are operating as satellite facilities
excluded from the prospective payment system as of that date. The
exception would not be available to hospitals that might be excluded
from the prospective payment system as of that date and at some later
time enter into satellite arrangements. In addition, we proposed not to
apply the rules for payments to satellite facilities to multicampus
arrangements, that is, those in which a hospital has a facility at two
or more locations but does not share a building or a campus with any
other hospital at those locations.
We also solicited comments 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 indicated that we were considering whether a
satellite facility opened by such a hospital should be exempt from the
proposed rules on satellites. We requested comment on this issue and on
whether this exclusion could be implemented without compromising the
effectiveness of the proposed changes.
We noted 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. We indicated that, if these operational
problems cannot be overcome, we would consider revising the regulations
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.
We received 18 comments on this proposal.
Comment: Several commenters objected to the proposal to pay
satellite facilities of excluded hospitals or units under a different
methodology than that used for the excluded hospital or unit itself.
These commenters argued that the potential abuses described in the
preamble to the proposed rule are likely to occur rarely, if at all,
and that differential payment for satellite facilities would interfere
with hospitals' flexibility to use their facilities efficiently and to
take advantage of economies of scale. Other commenters suggested that
the proposal, if adopted, could lead to a shortage of crucial
rehabilitation or long-term hospital services.
Most of the commenters suggested that the proposed changes be
withdrawn and that no limitations be placed on the ability of excluded
hospitals or units to establish satellite facilities and claim payment
for their services on the same basis as services in the rest of the
excluded hospital or unit. Other commenters suggested that we permit
services in satellite facilities to be paid on the same basis as
services in the remainder of the excluded hospital or unit only if
satellite facilities were created and operated under certain rules.
Some commenters, including a national health care association,
suggested that our concerns could be addressed if we limit the number
of satellite beds that an excluded hospital or unit could establish or
require that the satellite independently meet exclusion criteria.
Response: We have reviewed these comments and concluded that we can
address the concerns raised in the proposed rule, especially our
concerns with the application of the appropriate BBA cap on the
hospital target amount, without resorting to making payments for the
services provided in the satellite under a different methodology than
used for the original hospital or unit.
We have decided that, for purposes of payment, the satellite
facility of an excluded hospital or unit may be treated as a part of
the excluded hospital or unit and may receive payment on the same basis
as the excluded hospital or unit, but only if the following specific
criteria are met:
In the case of a hospital (other than a children's
hospital) or unit that was excluded from the prospective payment system
before the effective date of section 4414 of the BBA (cost reporting
periods beginning on or after October 1, 1997), the number of beds in
the hospital or unit (including both the base hospital or unit and the
satellite location) does not exceed the number of State-licensed and
Medicare-certified beds in the hospital or unit on the last day of the
hospital's or unit's last cost reporting period beginning before
October 1, 1997. Thus, while an excluded hospital or unit can
``transfer'' bed capacity from a base facility to a satellite, it
cannot, through the establishment of a satellite, increase total bed
capacity beyond the level it had in the most recent cost reporting
period prior to the effective date of section 4414.
The satellite facility independently complies with
selected prospective payment system exclusion requirements applicable
to the type of hospital unit. Specifically, a satellite of a children's
hospital must meet the requirement with respect to treatment of
inpatients who are predominantly individuals under age 18, as stated in
Sec. 412.23(d)(2); a satellite of a long-term care hospital must meet
the average length of stay requirement of Sec. 412.23(e)(1) through
(3)(i); a satellite of a rehabilitation hospital or unit must treat an
inpatient population meeting the requirement in Sec. 412.23(b)(2); and
a satellite of a psychiatric unit must meet the requirement regarding
admission of only psychiatric patients in Sec. 412.27(a).
The satellite facility complies with certain requirements
designed to ensure that costs are reported accurately for both the
hospital in which the satellite is located and the hospital of which
the satellite is a part. Specifically, a satellite of an excluded
hospital or unit must (1) have admission and discharge records that are
separately identified from those of the hospital in which it is located
and are readily available; (2) have beds that are physically separate
from (that is, not commingled with) the beds of the hospital in which
it is located; (3) be serviced by the same fiscal intermediary as the
hospital of which it is a part; (4) be treated as a separate cost
center of the hospital of which it is a part, for cost reporting and
apportionment purposes; (5) use an accounting system that properly
allocates costs; (6) maintain
[[Page 41534]]
adequate statistical data to support the basis of allocation; and (7)
report its costs in the cost report of the hospital of which it is a
part, covering the same fiscal period and using the same method of
apportionment as the hospital of which it is a part.
If an excluded hospital or unit has a satellite location and fails
to meet these requirements, the entire hospital or unit would lose its
exclusion from the prospective payment system. Under Secs. 412.22(d)
and 412.25(c), the change in status from excluded to included in the
prospective payment system would be effective at the start of the first
cost reporting period after the cost reporting period in which the
hospital or unit failed to meet the requirements. Loss of exclusion
status means that payment to the entire hospital or unit would then be
made under the prospective payment system.
Thus, under our policy, we permit a satellite facility to be
excluded (and treated as part of an excluded hospital) if certain
criteria are met, but deny excluded status to the entire hospital if
the criteria are not met. We are adopting this policy primarily because
of concerns about preventing inappropriate Medicare payments. As
explained above and in the proposed rule, we believe that hospitals
might be seeking satellite arrangements so that the services furnished
in the satellite facility are paid on an excluded basis when they
should be paid on a prospective payment basis. We also believe that
hospitals are seeking satellite arrangements in order to avoid the
effects of the payment caps that apply to new excluded hospitals under
the BBA. Therefore, we believe it is necessary and appropriate to
establish criteria for determining when a satellite facility may be
treated as part of the excluded hospital and paid on an excluded basis,
and to deny exclusion to the satellite facility if the satellite fails
to meet those criteria.
Another significant concern underlying our policy is
administratively feasibility. We believe it would be administrative
cumbersome, if not infeasible, to pay a satellite facility on a
different basis than the rest of the excluded hospital or unit.
Therefore, we believe that, if the satellite does not qualify for
exclusion, then it is necessary and appropriate to deny exclusion to
the entire hospital. If a hospital is considering whether to establish
a satellite facility, it should keep these payment rules in mind.
We note that these exclusion criteria would be administered in the
same manner as the general rules for excluded hospitals and hospital
units at Sec. 412.22 and the common requirements for excluded hospital
units at Sec. 412.25. Specifically, the HCFA Regional Office will
assess a hospital's or unit's compliance with the requirements before
the start of a cost reporting period and will implement the decision at
the start of the cost reporting period, effective for all of that
period.
One of the major concerns we had with payments for services at
satellites was the ability of a hospital to circumvent the intent of
the BBA by applying the higher cap for existing hospitals and units to
the beds in the new satellite. By requiring that the number of beds in
the expanded hospital or unit (including both the base hospital or unit
and the satellite location) cannot exceed the number of State-licensed
and Medicare-certified beds in the excluded hospital or unit at the
time the BBA was enacted, we ensure that the excluded hospital or unit
does not inappropriately circumvent the payment caps for new hospitals
enacted by the BBA. For hospitals and units first excluded from the
prospective payment system after the enactment date of the BBA, we
would not limit the number of beds in the hospital or unit, including
all satellites, since all beds in the hospital or unit necessarily will
be subject to the lower cap for new excluded hospitals and units. We
are not applying this requirement to children's hospitals since those
hospitals are not subject to caps established by the BBA.
Furthermore, by requiring that the satellite meet the prospective
payment system exclusion requirements applicable to the type of
hospital or unit, we are applying a policy to satellites that is
similar to that currently applicable to a hospital-within-a-hospital.
This policy, which is consistent with the suggestion of a national
health care association, will ensure that the satellite retains the
identity of the type of excluded hospital of which it is a part. For
example, if we allowed the 25-day length of stay for long-term care
hospital designation to be determined based on an examination of the
base long-term care hospital including the satellite, the satellite
could be excluded from the prospective payment system even if its
patients all had short lengths of stay. By calculating the length of
stay for patients exclusively at the satellite, we are ensuring that it
is, in fact, a long-term care facility that warrants being excluded
from the prospective payment system and receiving payment on a
reasonable cost basis. Under this approach, if the satellite facility
and the rest of the hospital or unit independently meet the applicable
exclusion criteria, then the entire entity will be treated as one
facility in making payments.
We also believe it is essential to be able to identify the costs of
satellite facilities separately from the costs of the host hospitals in
which they are located, so that services in both facilities are paid
for accurately and Medicare does not pay two facilities for the same
costs. To accomplish this, we will require the satellite to meet a
number of requirements relating to separate identification of the beds,
patients, and costs of the satellite. We note that these requirements
closely parallel similar requirements applicable to all excluded units
under Sec. 412.25(a)(3) and (a)(7) through (12).
We are revising Secs. 412.22(h) and 412.25(e) to implement this
policy.
Comment: Some commenters argued that paying satellite facilities of
excluded hospitals or units under a different methodology than that
used for the excluded hospital or unit itself would be inconsistent
with the Medicare law, in particular, sections 1886(b)(1) and (d)(1)(A)
and (D) of the Act.
Response: We believe that our policies are consistent with the
statutory scheme and the considerations underlying exclusions under the
prospective payment system, as well as our rulemaking authority under
section 1871 of the Act. Our policies addressing payments to satellite
facilities are designed to prevent inappropriate payments to hospitals
and to address potential fraud and abuse, and, at the same time, to
permit exclusion from the prospective payment system when the
circumstances warrant exclusion. As we discussed in the proposed rule,
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 payment 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 excluded hospitals.
Even if hospitals are not intentionally trying to ``game'' the system,
treating a satellite facility as ``part of'' the excluded hospital for
payment purposes might lead to inappropriate payments in a number of
ways.
We believe that Congress did not contemplate satellite arrangements
when it enacted section 1886(d) of the Act. Section 1886(d) does not
specifically address satellite
[[Page 41535]]
arrangements; also, section 1886(d) does not mandate that certification
status equate to payment status. The statute does, however, establish a
scheme under which entities may be excluded from the prospective
payment system. The purpose of exclusions is to recognize situations in
which the principles of the prospective payment system do not apply. As
we explained in the proposed rule, the considerations underlying
exclusions from the prospective payment system might not apply to
satellite facilities, which might be ``part of'' excluded hospitals
only ``on paper.'' Thus, we believe it is necessary and appropriate to
address Medicare payment for services furnished in satellite
facilities.
Comment: Several commenters approved of our proposal to grandfather
excluded hospitals or units structured as satellite facilities on
September 30, 1999, to the extent that they operate under the same
terms and conditions in effect on that date.
Response: We agree that grandfathering these facilities is
appropriate and are adopting this part of the proposed rule without
change. However, we wish to emphasize that this policy does not extend
to satellites established after September 30, 1999, even if they are
established by an excluded hospital or unit that has another satellite
that was grandfathered.
Comment: Two commenters expressed support for our proposal to not
apply the new satellite rules to any hospital excluded from the
prospective payment system by section 4417 of the BBA, as implemented
under Sec. 412.23(e)(2) (that is, a hospital that was first excluded in
1986, that had an average inpatient length of stay of greater than 20
days, and that demonstrated that at least 80 percent of its annual
Medicare inpatient discharges in the 12-month cost reporting period
ending in FY 1997 had a principal diagnosis that reflected a finding of
neoplastic disease).
Response: We agree with the commenters that this is appropriate and
are revising Sec. 412.22(h)(3) to reflect this policy.
In addition, as discussed earlier under section VI.B of this
preamble, we are including in Secs. 412.22(h)(4) and 412.25(e) a
corresponding exception to the requirement that a grandfathered
satellite facility be operated under the terms and conditions in effect
on September 30, 1999. The corresponding change would allow for
increases or decreases in square footage, or decreases in the number of
beds, of the satellite facility necessitated by changes for compliance
with Federal, State, and local law affecting the physical facility or
because of catastrophic events such as fires, floods, earthquakes, or
tornadoes.
D. Responsibility for Care of Patients in Hospitals-within-Hospitals
Generally, 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 in which, in these 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 circumventing,
through decreased length of stay, its target amount cap and receiving
inappropriate bonus and relief payments under section 4415 of the BBA.
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, in the
proposed rule, we discussed 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 was to provide that, if
an excluded hospital-within-a-hospital transfers patients from its beds
to beds of the prospective payment system hospital in which it is
located, the hospital-within-a-hospital would not qualify for exclusion
in the next cost reporting period. A second possible approach was to
provide that the hospital-within-a-hospital would qualify for exclusion
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.
After considering these options, we decided to propose a third
approach. We proposed to 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
stated that 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 in which 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 solicited 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.
We received 30 comments in response to our proposal and
solicitation.
Comment: Several commenters argued that the choice of a 5-percent
limit on discharges to the host prospective payment system hospital was
arbitrary, and that we did not cite any study or other empirical
evidence in support of it. Other commenters stated that the proposal
could discourage excluded
[[Page 41536]]
hospitals-within-hospitals from admitting medically complex cases, thus
contributing to a shortage of certain types of care. Other commenters,
including a number of physicians, respiratory therapists, and other
clinical personnel, expressed concern that the proposed rule could
discourage medically appropriate transfers and thus limit patients'
ability to receive needed care. One commenter indicated that the
proposed rule was stated only in terms of transfers from the excluded
hospital-within-a-hospital to the host prospective payment system
hospital, while the problems described in the preamble involve
transfers of patients from the excluded hospital-within-a-hospital to
the host prospective payment system hospital, followed by readmission
of the patient to the excluded hospital-within-a-hospital. Other
commenters suggested that while these transfers might be abusive, the
sanction identified in the proposed rule--loss of the exclusion from
the prospective payment system of the hospital-within-a-hospital--is
disproportionate to the problem.
Response: After review of all comments on this issue, we have
decided to modify our approach. First, we agree with those commenters
who stated that the primary focus of concern should not be discharges
from the excluded hospital-within-a-hospital to the host prospective
payment system hospital, but rather should include situations in which
the discharges are then followed by readmissions to the excluded
hospital-within-a-hospital, without any intervening movement of the
patient from the host hospital to a skilled nursing facility, his or
her home, or another hospital. Thus, we are revising the regulations to
address only the latter situations.
We also agree that there is a better way to address inappropriate
transfers and readmissions. When the level of inappropriate transfers
exceeds the threshold level described below, we will, instead of
terminating a hospital's exclusion, simply not consider the earlier
discharge in these cases to have occurred, for purposes of calculating
the payment to the hospital or unit. That is, if a patient is
discharged from an excluded hospital-within-a-hospital to the host
prospective payment system hospital and is then readmitted to the
excluded hospital-within-a-hospital directly from the host hospital,
the readmission would mean that the earlier discharge(s) from the
excluded hospital will not be taken into account in calculating
payments to the hospital-within-a-hospital under the excluded hospital
payment provisions and their implementing regulations in Sec. 413.40.
We also considered whether this policy should be applied in all
cases or only if a specific threshold is exceeded. We continue to
believe that the types of cases described (discharge of the patient to
the host prospective payment system hospital, followed by readmission
directly to the excluded hospital-within-a-hospital) are potentially
vulnerable to abuse and that, in principle, we should adopt a policy of
``zero tolerance'' for these cases. At the same time, we are aware that
this stringent approach might be difficult and controversial to
implement and could have the unintended effect of discouraging some
medically necessary or appropriate discharges to the host hospital.
Therefore, we will allow a 5-percent margin to hospitals for these
cases, in that we would not count the first discharge for purposes of
payment as an excluded hospital only when the excluded hospital's
number of these cases in a particular cost reporting year exceeded 5
percent of the total number of its discharges. If a hospital exceeds
this 5-percent threshold, we would, with respect to these cases, not
include any previous discharges to the host prospective payment system
hospital in calculating the excluded hospital's cost per discharge.
That is, the entire stay would be considered one ``discharge'' for
purposes of payments to the hospital.
For example, assume that a patient was discharged from the excluded
hospital-within-a-hospital to the prospective payment system hospital
in which it is located and then was readmitted to the excluded
hospital-within-a-hospital from the prospective payment system hospital
(the ``host''). If the total number of discharges (to all locations) of
the hospital-within-a-hospital in the cost reporting period is 100 and
the number readmitted from the host after having been previously
discharged to it is 3, the percentage would be 3 percent (3 divided by
100), and all of the discharges, including the previous discharge to
the host, would be taken into account. However, if the total number of
discharges had been only 50, and of those, 3 patients had been
readmitted from the host after a previous discharge to it, the
percentage would be 6 percent (3 divided by 50) and the first discharge
of the patients readmitted to the host would not be counted. Therefore,
payment would be based on 47 discharges. In determining whether a
patient had previously been discharged and then readmitted, we would
consider all prior discharges, even if the discharge occurred late in
one cost reporting period and the readmission occurred in the next cost
reporting period.
Thus, in the May 7, 1999 proposed rule, we proposed to deny
exclusion to a hospital-within-a-hospital 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. After considering the public comments, in this final rule we
are implementing a policy that differs from the proposed policy in two
significant ways. First, rather than focusing solely on discharges to
the host hospital, we are examining situations involving a discharge to
the host hospital followed by a readmission to the excluded hospital.
Second, if the 5-percent threshold is triggered, we would not deny
exclusion to the hospital-within-a-hospital; instead, the hospital-
within-a-hospital could continue to receive payment as an excluded
hospital-within-a-hospital, but, for purposes of determining the amount
of payment, we would not count the first discharge for those cases
involving a discharge followed by readmission. (If the 5-percent
threshold is not triggered, then all discharges would be counted.)
We continue to believe that the 5-percent threshold is appropriate
to trigger special payment rules. We are trying to prevent
inappropriate payments to hospitals for inappropriate transfers, and a
5-percent threshold reflects a balance of a number of considerations.
As indicated in the proposed rule, a 5-percent threshold would (1)
avoid the need for administratively burdensome case review (to
determine whether discharges or readmissions were inappropriate), (2)
provide adequate flexibility for transfers in those cases in which the
hospital-within-a-hospital is not equipped or staffed to provide the
services required by the patient, and (3) address possible incentives
for hospitals to transfer patients inappropriately.
The rationale for this policy is largely conceptual in nature, and
the 5-percent threshold is not based solely on any one source of
statistics or data available to us. If we tried to set a threshold
based solely on such statistics, it might be extremely difficult and
time-consuming to distinguish between appropriate transfers and
inappropriate transfers. Given the importance of preventing
inappropriate payments, we believe it would not be prudent to delay
implementing this policy. At this time, we believe that a 5-percent
``allowance'' reflects an appropriate balance of the considerations
discussed above and is
[[Page 41537]]
consistent with information available to us. However, we will continue
to monitor this issue and review data, and we might revise the
threshold in a future rulemaking if information indicates that a
revision is appropriate.
We are revising the definition of ``ceiling'' in Sec. 413.40(a)(3)
to implement our revised policy.
Comment: Some commenters asked whether the intent of the proposed
rule was to exclude hospitals-within-hospitals described under
Sec. 412.22(f) from the provision on responsibility for care of
patients, since the proposed rule would have added a new paragraph
(e)(6), and existing Sec. 412.22(f) states that the rules in paragraph
(e) do not apply to hospitals described in paragraph (f).
Response: As discussed above, we are not proceeding with the
proposed changes at Sec. 412.22(e)(6) and are instead implementing our
revised policy by amending the definition of ``ceiling'' in
Sec. 413.40(a)(3). The hospitals described in Sec. 412.22(f) will be
subject to the new policy on the same basis as other hospitals-within-
hospitals.
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).
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.
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, in the May 7, 1999 proposed rule,
we proposed 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 of 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 noted 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
requested comments on 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 were particularly interested in obtaining comments from
practitioners on the risks and benefits involved in adoption of this
practice.
We received three comments on our proposal.
Comment: Two commenters supported our proposal to allow a 60-minute
emergency response time for frontier areas.
Response: We appreciate the commenters' support and are adopting
this proposal as final without change.
Comment: One commenter believed that the 60-minute response
timeframe in the proposed rule is too long considering the importance
of timely provision of emergency care even in remote areas. The
commenter believes that if a facility wants to function as a CAH, it
should have appropriate personnel onsite within 30 minutes to provide
care.
Response: As we have indicated above, we believe that we must
recognize the special needs of sparsely populated rural areas in
meeting beneficiaries' health needs and at the same time protect
patients' health and safety. We believe our proposed change
accomplishes this goal.
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 this 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.
[[Page 41538]]
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 proposed 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.
Comments: We received three comments on this proposal. One
commenter supported our proposal and stated that the clarification
would help eliminate the confusion that has existed in the industry.
Another commenter noted that we do not have a comparable requirement
for screening patients in swing beds located in all other rural
hospitals and therefore believes it is inappropriate to implement a
standard for CAHs that exceed normal practice. Another commenter
objected to the proposed clarification as inflexible and biased and
urged us to defer implementing the screening policy for swing beds for
CAHs until we have established overall policy for swing beds.
Response: We believe that the changes we have proposed have revised
the rules to allow for flexibility for CAHs. As stated above, CAHs with
swing-bed approval are not paid for their services to SNF-level
patients under the SNF prospective payment system but are paid under
the payment method described in Sec. 413.114, which does not include a
case-mix adjustment. However, swing beds in rural hospitals are paid
under the SNF prospective payment system. As explained above, the
changes proposed to the reporting requirements for CAHs are intended to
allow the policy to be consistent with the payment policy for swing
beds in CAHs. With the change, we are making it explicit that the
patient assessment timeframes required under Secs. 413.343(b) and
483.20 do not apply to CAHs.
3. Additional Comments Received on CAH Issues
We received comments on two separate issues regarding CAHs on which
we did not propose policy changes.
Comment: One commenter believes that the definition of CAH is
prohibitive in one State and recommended that we change the criteria
for CAHs to allow a hospital that meets all the criteria except for
being located in an urban (versus a rural) area to be considered a CAH.
Response: We would need a change in the statute to authorize a
change in the requirements for CAH designation, as the commenter
recommended. Section 1820(c)(2)(B)(i) of the Act provides that a State
may designate a facility as a CAH only if the hospital is located in a
rural area as defined in section 1886(d)(2)(D) of the Act. Thus, we did
not revise our regulations to address this comment.
Comment: One commenter suggested that the reasonable cost payment
methodology for CAHs should extend to ambulance services and requested
that HCFA address this in the final rule.
Response: The provision of law governing payment for outpatient CAH
services, section 1834(g) of the Act, states that reasonable cost
payment is to be made for outpatient CAH services. These services are
defined, at section 1861(mm)(3) of the Act, as medical and other health
services furnished by a CAH on an outpatient basis. Consistent with our
policy on ambulance services, these services are treated under a
separate benefit and are covered and paid for under separate statutory
authority and a separate payment method. Therefore, we have no basis on
which to authorize reasonable cost payment for ambulance services .
VII. MedPAC Recommendations
As required by law, we reviewed the March 1, 1999 report submitted
by MedPAC to the Congress and gave its recommendations careful
consideration in conjunction with the proposals set forth in the May 7,
1999 proposed rule. We also responded to the individual recommendations
in the proposed rule. The comments we received on the treatment of the
MedPAC recommendations are set forth below, along with our responses to
those comments. However, if we received no comments from the public
concerning a MedPAC recommendation or our response to that
recommendation, we have not repeated the recommendation.
Recommendations concerning the update factors for inpatient operating
cost and for hospitals and hospital distinct part units excluded from
the prospective payment system are discussed in Appendix C of this
final rule.
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 in the Proposed Rule: 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.
Comment: We received two comments on our response to the MedPAC
recommendation regarding the wage related portion of the excluded
hospital target amount cap. Specifically, MedPAC commented that it
would encourage HCFA to seek legislative authority to adjust the target
amount caps for area wages. The other commenter asserted that such
adjustments should be made since they are used for new facilities and
because the exclusion of an adjustment is unfair to regions with higher
labor costs.
Response: In the May 12, 1998 final rule, we explained our decision
not to wage adjust the caps on the target amounts. The decision was
based on our analysis of the statutory language, the statutory scheme,
the legislative history, and policy considerations. First, we noted
that section 4414 of the BBA, which provides that ``* * * in the case
of a hospital or unit that is within a class of hospital described in
clause (iv), the Secretary shall estimate the 75th percentile of the
target amounts for such hospitals within such class for cost reporting
periods ending during fiscal year 1996,'' directs the Secretary to
examine target amounts and calculate a single number for each of three
classes of hospitals. In addition, we stated that while the statutory
language directs the Secretary to calculate the 75th percentile of
target amounts, it does not explicitly direct or even authorize the
Secretary to make adjustments to that
[[Page 41539]]
number after it is calculated. We agree that the absence of an explicit
instruction, in and of itself, does not necessarily mean that the
Secretary cannot implement a wage adjustment. However, Congressional
``silence'' on this issue must be construed in light of the statutory
scheme and the legislative history, as well as policy considerations.
With regard to the statutory scheme, we stated that in requiring
that we calculate a separate number for each class of hospitals, the
Congress established a scheme that directs us to recognize differences
across types of hospitals, but does not direct us to recognize
differences in wages. In addition to the scheme of section 4414 itself,
we considered this section in light of other statutory provisions. We
concluded that, because the Congress explicitly requires wage
adjustments in some contexts, failure to require a wage adjustment in
this context reflects a judgement by the Congress that we should not
make one under section 4414. In terms of the legislative history, we
noted that there is no reference in the Conference Report to a wage
adjustment to the TEFRA caps.
Finally, we asserted that while from a broad policy perspective a
wage adjustment might be appropriate, policy considerations do not
dictate a wage adjustment. A payment cap is different from a payment
rate in that a cap only affects hospitals that are above the cap, while
a payment rate affects all hospitals. Thus, we believe that while a
wage adjustment might be preferable policy, the lack of a wage
adjustment is not unreasonable. We stated that we would support a
hospital-sponsored legislative change to permit wage adjustments and we
will continue to do so; however, our decision, as expressed in the May
12, 1998 final rule, remains unchanged.
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. However,
the size of the payment adjustment 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 the
prospective payment system.
Response in the Proposed Rule: 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 the 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 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.
Comment: MedPAC commented that it does not believe that the
verification process for uncompensated care (charity and bad debt) data
needs to be burdensome. It recommends that HCFA keep reporting
requirements to a minimum to limit data collection problems.
Specifically, MedPAC recommends that HCFA collect only total
uncompensated care data rather than separate data on the two components
of uncompensated care--bad debts and charity care. HCFA should publish
guidelines specifying the types of unpaid charges that can be included
so that reporting problems are minimal.
Response: As we noted in our response to this recommendation in the
proposed rule, we are preparing a Report to Congress on the revision of
the DSH adjustment formula and have taken into consideration the
inclusion of a recommendation to collect uncompensated care charge data
by payer category (inpatient and outpatient) for our analysis. We
believe it is important to promote the consistent reporting of data to
the extent possible. We plan to minimize reporting problems by
collecting only total uncompensated care data, thereby avoiding the
problem of different definitions of bad debts, indigent care, and
uncompensated care among States. However, we continue to anticipate
other reporting problems such as hospital recordkeeping of these data.
VIII. Other Required Information
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. In our May 7, 1999
proposed rule, we published a list of data files that are available for
purchase (64 FR 24746 and 24747).
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.
[[Page 41540]]
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. In Sec. 412.2, the introductory text of paragraph (e) is
republished and paragraph (e)(4) is revised to read as follows:
Sec. 412.2 Basis of payment.
* * * * *
(e) Excluded costs. The following inpatient hospital costs are
excluded from the prospective payment amounts and are paid on a
reasonable cost basis:
* * * * *
(4) Heart, kidney, liver, lung, and pancreas acquisition costs
incurred by approved transplantation centers.
* * * * *
3. Section 412.22 is amended by adding a new paragraph (h) to read
as follows:
Sec. 412.22 Excluded hospitals and hospital units: General rules.
* * * * *
(h) Satellite facilities. (1) For purposes of paragraphs (h)(2)
through (h)(4) 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) Except as provided in paragraph (h)(3) of this section,
effective for cost reporting periods beginning on or after October 1,
1999, a hospital that has a satellite facility must meet the following
criteria in order to be excluded from the prospective payment systems
for any period:
(i) In the case of a hospital (other than a children's hospital)
that was excluded from the prospective payment systems for the most
recent cost reporting period beginning before October 1, 1997, the
hospital's number of State-licensed and Medicare-certified beds,
including those at the satellite facilities, does not exceed the
hospital's number of State-licensed and Medicare-certified beds on the
last day of the hospital's last cost reporting period beginning before
October 1, 1997.
(ii) The satellite facility independently complies with--
(A) For psychiatric hospitals, the requirements under
Sec. 412.23(a);
(B) For rehabilitation hospitals, the requirements under
Sec. 412.23(b)(2);
(C) For children's hospitals, the requirements under
Sec. 412.23(d)(2); or
(D) For long-term care hospitals, the requirements under
Secs. 412.23(e)(1) through (e)(3)(i).
(iii) The satellite facility meets all of the following
requirements:
(A) It maintains admission and discharge records that are
separately identified from those of the hospital in which it is located
and are readily available.
(B) It has beds that are physically separate from (that is, not
commingled with) the beds of the hospital in which it is located.
(C) It is serviced by the same fiscal intermediary as the hospital
of which it is a part.
(D) It is treated as a separate cost center of the hospital of
which it is a part.
(E) For cost reporting and apportionment purposes, it uses an
accounting system that properly allocates costs and maintains adequate
statistical data to support the basis of allocation.
(F) It reports its costs on the cost report of the hospital of
which it is a part, covering the same fiscal period and using the same
method of apportionment as the hospital of which it is a part.
(3) Except as provided in paragraph (h)(4) of this section, the
provisions of paragraph (h)(2) of this section do not apply to--
(i) Any hospital 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; or
(ii) Any hospital excluded from the prospective payment systems
under Sec. 412.23(e)(2).
(4) In applying the provisions of paragraph (h)(3) of this section,
any hospital structured as a satellite facility on September 30, 1999,
may increase or decrease the square footage of the satellite facility
or may decrease the number of beds in the satellite facility if these
changes are made necessary by relocation of a facility--
(i) To permit construction or renovation necessary for compliance
with changes in Federal, State, or local law; or
(ii) Because of catastrophic events such as fires, floods,
earthquakes, or tornadoes.
4. 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)
through (b)(3) of this section.
(1) Increase in size. Except as described in paragraph (b)(3) of
this section, 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. Except as described in paragraph (b)(3) of
this section, 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 its 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 must remain in
effect for the rest of that cost reporting period.
(3) Exception to changes in square footage and bed size. The number
of beds in an excluded unit may be decreased, and the square footage
considered to be part of the unit may be either increased or decreased,
at any time, if these changes are made necessary by relocation of a
unit--
(i) To permit construction or renovation necessary for compliance
with changes in Federal, State, or local law affecting the physical
facility; or
(ii) Because of catastrophic events such as fires, floods,
earthquakes, or tornadoes.
(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 the cost reporting period. If a unit
is added to a
[[Page 41541]]
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 must remain in effect for the rest of
that cost reporting period.
* * * * *
(e) Satellite facilities. (1) For purposes of paragraphs (e)(2)
through (e)(4) of this section, a satellite facility is a part of a
hospital unit 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) Except as provided in paragraph (e)(3) of this section,
effective for cost reporting periods beginning on or after October 1,
1999, a hospital unit that establishes a satellite facility must meet
the following requirements in order to be excluded from the prospective
payment systems for any period:
(i) In the case of a unit excluded from the prospective payment
systems for the most recent cost reporting period beginning before
October 1, 1997, the unit's number of State-licensed and Medicare-
certified beds, including those at the satellite facility, does not
exceed the unit's number of State-licensed and Medicare-certified beds
on the last day of the unit's last cost reporting period beginning
before October 1, 1997.
(ii) The satellite facility independently complies with--
(A) For a rehabilitation unit, the requirements under
Sec. 412.23(b)(2); or
(B) For a psychiatric unit, the requirements under Sec. 412.27(a).
(iii) The satellite facility meets all of the following
requirements:
(A) It maintains admission and discharge records that are
separately identified from those of the hospital in which it is located
and are readily available.
(B) It has beds that are physically separate from (that is, not
commingled with) the beds of the hospital in which it is located.
(C) It is serviced by the same fiscal intermediary as the hospital
unit of which it is a part.
(D) It is treated as a separate cost center of the hospital unit of
which it is a part.
(E) For cost reporting and apportionment purposes, it uses an
accounting system that properly allocates costs and maintains adequate
statistical data to support the basis of allocation.
(F) It reports its costs on the cost report of the hospital of
which it is a part, covering the same fiscal period and using the same
method of apportionment as the hospital of which it is a part.
(3) Except as specified in paragraph (e)(4) of this section, the
provisions of paragraph (e)(2) 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.
(4) In applying the provisions of paragraph (h)(3) of this section,
any unit structured as a satellite facility as of September 30, 1999,
may increase or decrease the square footage of the satellite facility
or may decrease the number of beds in the satellite facility at any
time, if these changes are made necessary by relocation of the
facility--
(i) To permit construction or renovation necessary for compliance
with changes in Federal, State, or local law affecting the physical
facility; or
(ii) Because of catastrophic events such as fires, floods,
earthquakes, or tornadoes.
Sec. 412.105 [Amended]
5. 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]
6. In Sec. 412.256, paragraph (c)(2), the date ``October 1'',
appearing in two places, is revised to read ``September 1''.
7. 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 adding a sentence containing
paragraphs (A) and (B) at the end of the definition of ``ceiling'' in
paragraph (a)(3) and revising paragraphs (b)(1)(iii), (c)(4)(v),
(f)(2)(ii)(A), and (g)(1) to read as follows:
Sec. 413.40 Ceiling on the rate-of-increase in hospital inpatient
costs.
(a) Introduction. * * *
(3) Definitions. * * *
Ceiling * * * For a hospital-within-a-hospital, as described in
Sec. 412.22(e) of this chapter, the number of Medicare discharges in a
cost reporting period does not include discharges of a patient to
another hospital in the same building on or on the same campus, if--
(A) The patient is subsequently readmitted to the hospital-within-
a-hospital directly from the other hospital; and
(B) The hospital-within-a-hospital has discharged to the other
hospital and subsequently readmitted more than 5 percent (that is, in
excess of 5.0 percent) of the total number of inpatients discharged
from the hospital-within-a-hospital in that cost reporting period.
* * * * *
(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 an excluded unit or an
excluded unit becomes a freestanding hospital, or an entity of a
multicampus hospital becomes a newly created hospital or unit or a
hospital or unit becomes a part of a multicampus hospital), the base
period for the hospital or unit that
[[Page 41542]]
changed its operational structure is the first cost reporting period of
at least 12 months effective with the revised Medicare certification
classification.
* * * * *
(c) Cost subject to the ceiling. * * *
(4) Target amounts. * * *
(v) In the case of a hospital that received payments under
paragraph (f)(2)(ii) of this section as a newly created hospital or
unit, to determine the hospital's target amount for the hospital's
third 12-month cost reporting period, the payment amount determined
under paragraph (f)(2)(ii) of this section for the preceding cost
report period is updated to the third cost reporting period.
* * * * *
(f) Comparison to the target amount for new hospitals and units. *
* *
(2) Comparison. * * *
(ii) Median target amount. (A) For cost reporting periods beginning
on or after October 1, 1997, the amount of payment for a new
psychiatric hospital or unit, a new rehabilitation hospital or unit, or
a new long-term care hospital that was not paid as an excluded hospital
prior to October 1, 1997, is the lower of the hospital's net inpatient
operating cost per case or 110 percent of the national median of the
target amounts for the class of excluded hospitals and units
(psychiatric, rehabilitation, long-term care) as adjusted for
differences in wage levels and updated to the first cost reporting
period in which the hospital receives payment. The second cost
reporting period is subject to the same target amount as the first cost
reporting period.
* * * * *
(g) Adjustment. (1) General rules. (i) HCFA adjusts 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 the hospital requests an adjustment, 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 the hospital requests an adjustment, 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 as set forth below.
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, (g)(6)(i) and (ii), and the
first sentence of paragraph (g)(6)(iii) 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.
* * * * *
(b) * * *
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.
* * * * *
(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 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 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
[[Page 41543]]
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) An urban hospital that qualifies for an adjustment to its FTE
cap under paragraph (g)(6)(i) of this section is not permitted to be
part of an affiliated group for purposes of establishing an aggregate
FTE cap.
(E) A rural hospital that qualifies for an adjustment to its FTE
cap under paragraph (g)(6)(i) of this section is permitted to be part
of an affiliated group for purposes of establishing an aggregate FTE
cap.
(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.
(iii) If a hospital with allopathic or osteopathic residents in its
most recent cost reporting period ending on or before December 31,
1996, is located in a rural area (or other hospitals located in rural
areas that added residents under paragraph (g)(6)(i) of this section),
the hospital's unweighted FTE limit may be adjusted in the same manner
described in paragraph (g)(6)(ii) of this section to reflect the
increase for residents in the new medical residency training programs
established after August 5, 1997. * * *
(7) A hospital that began construction of its facility prior to
August 5, 1997, and sponsored new medical residency training programs
on or after January 1, 1995 and on or before August 5, 1997, that
either received initial accreditation by the appropriate accrediting
body or temporarily trained 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 newly established program 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 new 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 programs begun at
the temporary training site.
(iii) If the new 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 programs (including the years at the temporary
training site).
(iv) A hospital that qualifies for an adjustment to its FTE cap
under paragraph (g)(7) of this section may be part of an affiliated
group for purposes of establishing an aggregate FTE cap.
(v) 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) No later than 60 days after 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.
(iii) For purposes of paragraph (g)(8) of this section, ``closure''
means the hospital terminates its Medicare agreement under the
provisions of Sec. 489.52 of this chapter.
* * * * *
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) of this
section. 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:
[[Page 41544]]
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 all of the
following requirements are met:
(i) The CAH is located in an area designated as a frontier area
(that is, an area with 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.
(iii) The State maintains documentation showing that the response
time of up to 60 minutes at a particular CAH it designates is 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. The 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: July 21, 1999.
Michael M. Hash,
Deputy Administrator, Health Care Financing Administration.
Dated: July 22, 1999.
Donna E. Shalala,
Secretary.
Editorial Note: The following addendum and appendixes will not
appear in the Code of Federal Regulations.
Addendum--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 amounts and factors for
determining prospective payment rates for Medicare inpatient operating
costs and Medicare inpatient capital-related costs. We are also setting
forth 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 making changes in the
determination of the prospective payment rates for Medicare inpatient
operating costs for FY 2000. The changes, to be applied prospectively,
affect the calculation of the Federal rates. In section III of this
addendum, we are updating the payments per unit for blood clotting
factor provided to hospital inpatients who have hemophilia. We are also
adding another product (clotting factor, porcine (HCPCS code J7191)) to
the list of clotting factors that are paid under this benefit.
In section IV of this addendum, we discuss our changes for
determining the prospective payment rates for Medicare inpatient
capital-related costs for FY 2000. Section V of this addendum sets
forth our 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 this final rule are
presented at the end of this addendum in section VI.
II. 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 factors used for determining the
prospective payment rates. The Federal and Puerto Rico rate changes,
once issued as final, will 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 standardized amounts set forth in Tables 1A and 1C
of section VI of this addendum reflect--
Updates of 1.1 percent for all areas (that is, the market
basket percentage increase of 2.9 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;
[[Page 41545]]
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 revising the discharge-weighted
national standardized amount for Puerto Rico to reflect the proportion
of discharges in large urban and other areas from the FY 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. We
note that on July 6, 1999, the Office of Management and Budget
announced the designation of the Corvallis, Oregon and the Auburn-
Opelika, Alabama MSAs. We have incorporated these changes in this final
rule.
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 updating 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 hospital market
basket increase for FY 2000 is 2.9 percent. Thus, for FY 2000, the
update to the average standardized amounts equals 1.1 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 final recommendation of update factors for FY 2000 for both
prospective payment hospitals and hospitals excluded from the
prospective payment system. We have included our final recommendations
in Appendix C to this final 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
[[Page 41546]]
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 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 0.997808. 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 0.999745. 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 will continue 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. In the May 7, 1999 proposed rule, we applied an
adjustment factor of 0.994453 to ensure that the effects of
reclassification are budget neutral. The final budget neutrality
adjustment factor is 0.993799.
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 are reflected in the final
budget neutrality adjustment required under section 1886(d)(8)(D) of
the Act and published in this final rule.
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.
i. FY 2000 outlier thresholds. 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.
For FY 2000, we proposed to establish a fixed loss cost outlier
threshold equal to the prospective payment rate for the DRG plus the
IME and DSH payments plus $14,575 ($13,309 for hospitals that have not
yet entered the prospective payment system for capital related costs).
In addition, we proposed to maintain the marginal cost factor for cost
outliers at 80 percent. In setting the final FY 2000 outlier
thresholds, we used updated data. In this final rule, we are
establishing a fixed loss cost outlier threshold for FY 2000 equal to
the prospective payment rate for the DRG plus the IME and DSH payments
plus $14,050 ($12,827 for hospitals that have not yet entered the
prospective payment system for capital related costs). In addition, we
are maintaining the marginal cost factor for cost outliers at 80
percent. 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. We are
using a cost inflation factor of zero percent to set the final FY 2000
outlier thresholds. 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.
ii. Other changes concerning outliers. In accordance with section
1886(d)(5)(A)(iv) of the Act, we calculated outlier thresholds so that
outlier payments are projected to equal 5.1 percent of total payments
based on DRG prospective payment rates. In
[[Page 41547]]
accordance with section 1886(d)(3(E), we reduced the FY 2000
standardized amounts by the same percentage to account for the
projected proportion of payments paid to outliers.
As stated in the September 1, 1993 final rule (58 FR 46348), we
establish outlier thresholds that are applicable to both inpatient
operating costs and inpatient capital-related costs. When we modeled
the combined operating and capital outlier payments, we found that
using a common set of thresholds resulted in a higher percentage of
outlier payments for capital-related costs than for operating costs. We
project that the 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 were as follows:
------------------------------------------------------------------------
Operating Capital
standardized federal
amounts rate
------------------------------------------------------------------------
National....................................... 0.948934 0.9397
Puerto Rico.................................... 0.969184 0.9334
------------------------------------------------------------------------
The final outlier adjustment factors applied to the standardized
amounts for FY 2000 are as follows:
------------------------------------------------------------------------
Operating Capital
standardized federal
amounts rate
------------------------------------------------------------------------
National....................................... 0.948859 0.9402
Puerto Rico.................................... 0.968581 0.9331
------------------------------------------------------------------------
As in the proposed rule, we apply the 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 fiscal intermediary is unable to
compute a reasonable hospital-specific cost-to-charge ratio. Effective
October 1, 1999, these Statewide average ratios replace the ratios
published in the July 31, 1998 final rule (63 FR 41099). 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 fiscal intermediary computes
operating cost-to-charge ratios lower than 0.209551 OR greater than
1.284349 and capital cost-to-charge ratios lower than 0.01290 or
greater than 0.17205. 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 will 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.
iii. FY 1998 and FY 1999 outlier payments. 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
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 6.3 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 March 1999 update of
the provider-specific file and the March 1999 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.
Comment: Several commenters indicated that the proposed 30-percent
increase in the cost outlier threshold is too great and implementing
that threshold will cause significant revenue losses for hospitals with
large numbers of high-cost cases. They observed that the proposed
increase in the fixed loss threshold may be reasonable to reach the 5.1
percent level of outlier payments, but suggested an increase in funding
for outlier cases from the current level of 5.1 percent to 5.5 percent,
or even 6.0 percent, with a corresponding reduction in the fixed loss
threshold.
Response: Outlier payments are meant to protect hospitals against
the financial effects of treating extraordinarily high-cost cases.
Increasing the level of outlier payments to 5.5 percent would result in
a corresponding offset to the standardized amounts, proportionally
reducing payments for typical cases. We believe that it is in the best
interest of hospitals and the program to maintain the level of outliers
at 5.1 percent, thereby providing all hospitals with somewhat larger
rates for typical cases.
We also note that we estimate that actual outlier payments for FY
1998 were equal to 6.5 percent of actual total DRG payments, and 6.3
percent for FY 1999. We believe that outlier payments are greater than
expected for these years in part because actual hospital costs may be
higher than reflected in the methodology used to set outlier thresholds
for those years. While we are attempting to improve our estimate of
payments for FY 2000 by using a cost inflation factor of zero percent
rather than a negative inflation factor, we believe it would be
imprudent to raise the estimated level of outlier payments at a time
when actual outlier payments have exceeded our estimates by more than
one percentage point for the past 2 years.
Comment: One commenter expressed concern that, in the proposed
rule, we referenced our longstanding policy regarding overpayments and
underpayments and retroactive adjustments to outlier payments. The
commenter stated that this reference appears to be necessitated by a
large number of hospital appeals and questioned whether we intend to
provide a clarification instead of what appears to be a new
interpretation.
Response: As we stated in the proposed rule, our statement that
``we do not plan to recoup money and make retroactive adjustments to
outlier payments for FY 1998,'' because the actual outlier payments
exceed 6 percent of total payments, is consistent with the policy and
statutory interpretation we have maintained since the inception of the
prospective payment system. We have publicly stated our policy on
several occasions. For example, in the January 3, 1984 final rule (49
FR 234, 265), we stated:
[[Page 41548]]
``Using data we had available, we set the outlier criteria so that an
estimated 6 percent of total payments would be made for outliers.
Nevertheless, there is no necessary connection between the amount of
estimated outlier payments and the actual payments made to hospitals
for cases that actually meet the outlier criteria. While we expect that
under these criteria, outlier payments will approximate 6 percent of
total payments, we will pay for any outlier that meets the criteria,
even if aggregate outlier payments result in more than 6 percent of
total payments.'' Also, in the September 1, 1992 final rule (57 FR
39784), we stated that ``* * * in light of the nature of the
prospective payment system, and our attempts to estimate outlier
payments as accurately as possible, we believe that we have satisfied
the statute and that no retroactive adjustment is warranted.'' In the
same rule, we also stated that ``* * * retroactive adjustment of system
wide elements would be contrary to the nature of the prospective
payment system.'' Therefore, our comment in the proposed rule
concerning the overpayment or underpayment of outliers was a
restatement of our longstanding policy.
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 are 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 labor-
related and nonlabor-related shares 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 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 FY 2000 wage
index. The wage index is set forth in Tables 4A through 4F of this
addendum.
2. Adjustment for Cost of Living in Alaska and Hawaii
Section 1886(d)(5)(H) of the Act authorizes an adjustment to take
into account the unique circumstances of hospitals in Alaska and
Hawaii. Higher labor-related costs for these two States are taken into
account in the adjustment for area wages described above. For FY 2000,
we are adjusting 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.
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 will 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
[[Page 41549]]
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 increasing the hospital-specific rates by 1.1 percent (the
hospital market basket percentage increase of 2.9 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 Medicare-dependent, small rural
hospitals, the applicable FY 2000 hospital-specific rate is calculated
by increasing the hospital's hospital-specific rate for the preceding
fiscal year by the applicable update factor (1.1 percent), which is the
same as the update for all prospective payment hospitals. In addition,
the hospital-specific rate is adjusted by the budget neutrality
adjustment factor (that is, 0.997808) as discussed in section II.A.4.a
of this Addendum. The resulting rate is 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.
Comment: One commenter asked if the temporary relief payment
provision of the Balanced Budget Act of 1997 (BBA) would continue into
FY 2000. The commenter suggested that, in light of reports that
implementation of the hospital-related provisions of the BBA provided
larger than expected savings, we consider extending the provision into
next year and increasing the amount of relief.
Response: Under section 4401(b) of the BBA, the temporary special
payment for certain hospitals that did not receive IME or DSH payments
and that did not qualify as Medicare-dependent, small rural hospitals
is limited to FY 1998 and FY 1999. The statute does not provide for the
special payment in later fiscal years. We believe that the temporary
special payment provided under section 4401(b) of the BBA was meant to
partially protect qualifying hospitals from the initial effects of the
reduced updates to hospital payment rates enacted by the BBA. We
believe that two years of relief payments is adequate to allow
hospitals to adjust to the reduced payment updates under the BBA.
III. Changes to the Payment Rates for Blood Clotting Factor for
Hemophilia Inpatients
As discussed in our May 7, 1999 proposed rule (64 FR 24756),
section 4452 of the BBA 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. The add-on payment amount for each clotting factor, as described
in HCFA's Common Procedure Coding System (HCPCS), is based on the
median average wholesale price (AWP) of the several products available
in that category of factor, discounted by 15 percent.
Also, we are adding 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, the prices per unit of
factor for FY 2000 are as follows:
J7190 Factor VIII (antihemophilic factor, human)................. 0.79
[[Page 41550]]
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, nonrecombinant) 0.97
Q0161 Factor IX (antihemophilic factor, recombinant)............. 1.00
These prices for blood clotting factor administered to inpatients
who have hemophilia will be effective for discharges beginning on or
after October 1, 1999 through September 30, 2000. Payment will be made
for the blood clotting factor only if there is an ICD-9-CM diagnosis
code for hemophilia included on the bill.
We received one comment on this proposed provision.
Comment: One commenter indicated that there is a new clotting
factor product, recombinant coagulation Factor VIIa, that is covered by
this benefit, but was not mentioned in the proposed rule. Because this
product is unique and packaged and dosed per microgram, and not per IU
as the other clotting factor products listed in the HCPCS, the
commenter requested a separate temporary code and price to be added to
the final rule.
Response: We agree that recombinant coagulation Factor VIIa is
covered by this benefit. We also agree that no appropriate HCPCS code
exists for this product. Because of constraints on Year 2000 computer
systems changes, we are not able to establish a new HCPCS code or a
claims process to pay for this product at this time. Therefore, any
providers furnishing recombinant coagulation Factor VIIa to hospital
inpatients who have hemophilia should hold their billings for Factor
VIIa until we announce by instructions to our fiscal intermediaries
that a new code and claims process have been established. These
hospitals should continue to submit claims for all other covered items
and services furnished to these Medicare beneficiaries in accordance
with established program procedures. The price for recombinant
coagulation Factor VIIa for FY 2000 will be $1.19 per microgram.
IV. 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 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 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 final 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 enactment 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
[[Page 41551]]
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. In the proposed
rule, we stated that the proposed FY 2000 Federal rate was $374.31. In
this final rule, we are establishing a FY 2000 Federal rate of $377.03.
In the discussion that follows, we explain the factors that were
used to determine the FY 2000 capital Federal rate. In particular, we
explain why the FY 2000 Federal rate has decreased 0.28 percent
compared to the FY 1999 Federal rate. Even though the FY 2000 Federal
capital rate is less than the FY 1999 Federal rate, we estimate
aggregate capital payments will increase by 3.64 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 rule reflected an update factor of -0.6 percent, based on the
data available at that time. Under the update framework, the final
update factor for FY 2000 is 0.3 percent. This update factor is based
on a projected 0.6 percent increase in the CIPI, a 0.1 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.
Below we describe the policy adjustments that have been applied to
the FY 2000 capital payment rates update.
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'').
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 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 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 -0.1 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. In the
framework, we make an adjustment for DRG reclassification and
recalibration to account for the 2-year lag on the available data used
to estimate the effect of DRG changes. A DRG reclassification and
recalibration adjustment of 0.1 percentage points was calculated for
the FY 2000 update as the 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 based on FY 1998
data. That is, in determining the effect of DRG reclassification and
recalibration using FY 1998 data, the actual effect of DRG
reclassification and recalibration was understated by -0.1 percent.
Therefore, we are making a 0.1 percent adjustment for DRG
reclassification and recalibration in the update for FY 2000.
Comment: One commenter noted that the magnitude of the -0.7
adjustment for FY 1998 Reclassification and Recalibration (GROUPER
Effect) in the proposed capital (and operating) update framework
appears to be inconsistent with past numbers published by HCFA.
Accordingly, the commenter requested that HCFA review the data and
computation of that adjustment in the capital update framework.
Response: In the May 7, 1999 proposed rule (64 FR 24578), we
estimated that FY 1998 DRG reclassification and recalibration resulted
in a 0.7 percent change 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 DRGs. Therefore, we
proposed making a -0.7 percent adjustment for DRG reclassification and
recalibration in the proposed capital update recommendation for FY
2000.
Upon review, we have discovered that incorrect data were used in
estimating the proposed -0.7 adjustment for the effect of FY 1998
reclassification and recalibration. We have recalculated the adjustment
based on correct and updated data and the revised adjustment for the
effect of FY 1998 reclassification and recalibration for the FY 2000
capital update is +0.1.
The capital update framework contains an adjustment for forecast
[[Page 41552]]
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
incorrect 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 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 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 through FY 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 making a 0.0 percent
intensity adjustment for FY 2000.
In summary, the FY 2000 final capital update under our framework is
0.3 percent. This update is based on a projected 0.6 increase in the
CIPI, policy adjustment factors of 0.0, a 0.1 adjustment for the effect
of FY 1998 reclassification and recalibration, and a forecast error
correction of -0.4.
b. Comparison of HCFA and MedPAC Update Recommendations.
As discussed in the proposed rule, MedPAC recommended a -1.1 to 1.8
percent update to the standard capital Federal rate and we recommended
a -0.6 percent update. (See the May 7, 1999 proposed rule for the
differences between the MedPAC and HCFA update frameworks (64 FR
24758)). In this final rule, as discussed in the previous section, we
are implementing a 0.3 percent update to the capital Federal rate.
Comment: MedPAC noted that our update recommendation of -0.6
percent was within the range of the -1.1 to 1.8 percent that they
recommended. They also asserted 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
prospective capital payment is completed, a single prospective payment
rate should be developed for hospital inpatient services to Medicare
beneficiaries. MedPAC indicated that a single prospective payment rate
for both operating and capital costs would be consistent with the way
that hospitals purchase a majority of goods and services. MedPAC plans
to investigate options for coordinating the capital and operating
updates and would be pleased to work with HCFA on this effort.
Response: We responded to a similar comment in the May 7, 1999
proposed rule (64 FR 24759), 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 and
[[Page 41553]]
may examine combining the payment systems after the conclusion of the
capital prospective payment transition period. While we welcome
MedPAC's assistance in the eventual development of a unified operating
and capital update framework, we believe that developing a unified
operating and capital update framework would become a higher priority
if the actual operating update was no longer determined by Congress
through the statute and the unified update would be appropriately
applied directly to a combined payment rate for operating and capital
costs.
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.
For FY 2000, we estimate that outlier payments for capital will equal
5.98 percent of inpatient capital-related payments based on the Federal
rate. Therefore, we are establishing an outlier adjustment factor of
0.9402 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 net change in the outlier adjustment to
the Federal rate for FY 2000 is 1.0011 (0.9402/0.9392). The outlier
adjustment increases the FY 2000 Federal rate by 0.11 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, 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. In the proposed rule for FY 2000, we
proposed a GAF/DRG budget neutrality factor of 0.9986. In this final
rule, based on calculations using updated data, we are applying a
factor of 0.9985. 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 incremental change in the
adjustment from FY 1999 to FY 2000 is 0.9985. The cumulative change in
the rate due to this adjustment is 1.0014 (the product of the
incremental factors for FY 1993, FY 1994, FY 1995, FY 1996, FY 1997, FY
1998, FY 1999, and FY 2000: 0.9980 x 1.0053 x 0.9998 x 0.9994 x
0.9987 x 0.9989 x 1.0028 x 0.9985 = 1.0014).
This factor accounts for DRG reclassifications and recalibration
and for changes in the GAF. It also incorporates the effects on the GAF
of FY 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 an actuarial model described in
Appendix B to determine the exceptions payment adjustment factor.
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. In the
May 7, 1999 proposed rule, we estimated that exceptions payments for FY
2000 would equal 2.48 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. Therefore, we proposed an
exceptions payment reduction factor of 0.9752 to the Federal rate for
FY 2000. For this final rule, based on updated data, we estimate that
exceptions payments for FY 2000 will equal 2.70 percent of aggregate
payments based on the Federal rate and hospital-specific rate. We are,
therefore, applying an exceptions payment reduction factor of 0.9730
(1--0.0270) to the Federal rate for FY 2000. The final exceptions
reduction factor for FY 2000 is 0.54 percent lower than the factor for
FY 1999 and 0.23 percent lower than the factor in the FY 2000 proposed
rule.
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 net adjustment to the FY 2000 Federal
rate is 0.9730/0.9783, or 0.9946.
[[Page 41554]]
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 proposed to the factors used to
establish the Federal rate, we proposed that the FY 2000 Federal rate
would be $374.31. In this final rule, we are establishing a FY 2000
Federal rate of $377.03. The Federal rate for FY 2000 was calculated as
follows:
The FY 2000 update factor is 1.0030; that is, the update
is 0.30 percent.
The 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 0.9985.
The FY 2000 outlier adjustment factor is 0.9402.
The FY 2000 exceptions payments adjustment factor is
0.9730.
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 have made 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 FY 2000 Federal
rate in comparison to the FY 1999 Federal rate. The FY 2000 update
factor has the effect of increasing the Federal rate by 0.30 percent
compared to the rate in FY 1999, while the final geographic and DRG
budget neutrality factor has the effect of decreasing the Federal rate
by 0.15 percent. The FY 2000 outlier adjustment factor has the effect
of increasing the Federal rate by 0.11 percent compared to FY 1999. The
FY 2000 exceptions reduction factor has the effect of decreasing the
Federal rate by 0.54 percent compared to the exceptions reduction for
FY 1999. The combined effect of all the changes is to decrease the
Federal rate by 0.28 percent compared to the Federal rate for FY 1999.
Comparison of Factors and Adjustments: FY 1999 Federal Rate and FY 2000 Federal Rate
----------------------------------------------------------------------------------------------------------------
Percent
FY 1999 FY 2000 Change change
----------------------------------------------------------------------------------------------------------------
Update Factor \1\........................................... 1.0010 1.0030 1.0030 0.30
GAF/DRG Adjustment Factor \1\............................... 1.0028 0.9985 0.9985 -0.15
Outlier Adjustment Factor \2\............................... 0.9392 0.9402 1.0011 0.11
Exceptions Adjustment Factor \2\............................ 0.9783 0.9730 0.9946 -0.54
Federal Rate................................................ $378.10 $377.03 0.9972 -0.28
----------------------------------------------------------------------------------------------------------------
\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 0.9985 GAF/DRG
budget neutrality factor for FY 2000 is 0.9985.
\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 0.9402/0.9392, or 1.0011.
As stated previously in this section, the FY 2000 Federal rate has
decreased 0.28 percent compared to the FY 1999 Federal rate, even
though the capital rate update factor has increased from 0.1 percent in
FY 1999 to 0.3 percent in FY 2000. The 0.28 percent decrease in the
Federal capital rate is a result of the combination of the FY 2000
factors and adjustments applied to the Federal rate. Specifically, the
exceptions reduction factor decreased 0.54 percent from 0.9783 for FY
1999 to 0.9730 for FY 2000, which results in a larger reduction to the
Federal capital rate for FY 2000 compared to FY 1999. Also, the GAF/DRG
adjustment factor decreased 0.42 percent from 1.0027 for FY 1999 to
0.9985 for FY 2000, which results in a decrease the Federal capital
rate for FY 2000 compared to FY 1999. The outlier adjustment factor
increased 0.11 percent from 0.9392 for FY 1999 to 0.9402 for FY 2000,
which results in an increase to the Federal capital rate for FY 2000
compared to FY 1999. The effect of all of these changes is a -0.28
percent decrease in the FY 2000 Federal rate compared to FY 1999.
Even though the FY 2000 Federal capital rate is less than the FY
1999 Federal rate, we estimate that aggregate capital payments will
increase 3.64 percent during this same period, primarily due to the
increase in the Federal blend percentage (from 80 to 90 percent) for
fully prospective payment hospitals.
We are also providing a chart that shows how the final FY 2000
Federal rate differs from the proposed FY 2000 Federal rate.
Comparison of Factors and Adjustments: FY 2000 Proposed Federal Rate and FY 2000 Final Federal Rate
----------------------------------------------------------------------------------------------------------------
Proposed FY Final FY Percent
2000 2000 Change change
----------------------------------------------------------------------------------------------------------------
Update Factor \1\........................................... 0.9940 1.0030 1.0091 0.91
GAF/DRG Adjustment Factor................................... 0.9986 0.9985 0.9999 -0.01
Outlier Adjustment Factor................................... 0.9397 0.9402 1.0005 0.05
Exceptions Adjustment Factor................................ 0.9752 0.9730 0.9977 -0.23
Federal Rate................................................ $374.31 $377.03 1.0073 0.73
----------------------------------------------------------------------------------------------------------------
\1\ As noted previously in section IV.A.1.a of this addendum, upon review we discovered that incorrect data were
used in estimating the proposed adjustment for the effect of FY 1998 reclassification and recalibration in the
proposed rule. As a result, the revised adjustment for the effect of FY 1998 reclassification and
recalibration for the capital update for FY 2000 is +0.1 (compared to the proposed -0.7). Accordingly, the FY
2000 final update is 0.30 (compared to the proposed -0.06), which accounts for the 0.73 increase in the
Federal rate from the FY 2000 proposed to FY 2000 final rule.
[[Page 41555]]
6. Special Rate for Puerto Rico Hospitals
As explained above, 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 prospective payment system 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
applied separate budget neutrality adjustments for the national GAF and
for the Puerto Rico GAF. We applied the same budget neutrality factor
for DRG reclassifications and recalibration nationally and for Puerto
Rico. The Puerto Rico GAF budget neutrality factor is 0.9991, while the
DRG adjustment is 0.9999, for a combined cumulative adjustment of
0.9990.
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 required by the BBA. For FY 1999, before
application of the GAF, the special rate for Puerto Rico hospitals was
$181.10. With the changes we proposed to the factors used to determine
the rate, the proposed FY 2000 special rate for Puerto Rico was
$174.15. In this final rule, the FY 2000 capital rate for Puerto Rico
is $174.81.
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 updating the hospital-specific
rate by a factor of 1.0030.
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 estimated in the proposed
rule that exceptions payments would be 2.48 percent of aggregate
payments based on the Federal rate and the hospital-specific rate.
Therefore, we proposed that the updated hospital-specific rate be
reduced by a factor of 0.9752. In this final rule, we estimate that
exceptions payments will be 2.70 percent of aggregate payments based on
the Federal rate and hospital-specific rate. Accordingly, for FY 2000,
we are applying an exceptions reduction factor of 0.9730 to the
hospital-specific rate. 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 net
adjustment to the FY 2000 hospital-specific rate is 0.9730/0.9783, or
0.9946.
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 cumulative
net adjustment from FY 1999 to FY 2000 is 0.9976, which represents a
decrease of 0.24 percent to the hospital-specific rate. For each
hospital, the FY 2000 hospital-specific rate is determined by
multiplying the FY 1999 hospital-specific rate by the cumulative net
adjustment of 0.9976.
FY 2000 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
Final FY Net Percent
FY 1999 2000 adjustment change
----------------------------------------------------------------------------------------------------------------
Update Factor............................................... 1.0010 1.0030 1.0030 0.30
Exceptions Payment Adjustment Factor........................ 0.9783 0.9730 0.9946 -0.54
Cumulative Adjustments...................................... 0.9793 0.9769 0.9976 -0.24
----------------------------------------------------------------------------------------------------------------
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 1.0030. 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 0.9730/0.9783, or 0.9946.
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
hospital (DSH) adjustment factor, and the indirect medical education
(IME) adjustment factor, when appropriate).
If the hospital-specific rate is higher than the applicable Federal
rate, the hospital is paid under the hold-harmless methodology. If the
hospital-specific rate is lower than 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,
[[Page 41556]]
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 + DSH Adjustment Factor + IME Adjustment Factor). 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 outlier thresholds for FY 2000 are in section II.A.4.c of this
Addendum. For FY 2000, a case qualifies as a cost outlier if the cost
for the case is greater than the prospective payment rate for the DRG
(and any IME and DSH payments) plus $14,050.
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 minimum payment levels for portions of cost
reporting periods occurring in FY 2000 are as follows:
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.
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 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, American Hospital Association (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 on August 29, 1997 (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
[[Page 41557]]
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), July 31, 1998 (63 FR 41017), and
May 7, 1999 (64 FR 24763).
2. Forecast of the CIPI for Federal Fiscal Year 2000
We are forecasting the CIPI to increase 0.6 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 3.5 percent increase in other capital expense prices
in FY 2000, partially offset by a 2.9 percent decline in vintage-
weighted interest rates in FY 2000. The weighted average of these three
factors produces the 0.6 percent increase for the CIPI as a whole.
V. Changes to Payment Rates for Excluded Hospitals and Hospital
Units: Rate-of-Increase Percentages
The inpatient operating costs of hospitals and hospital units
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of
the Act, which is implemented in 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 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 2.9 percent. Therefore, the update to a hospital's target
amount for its cost reporting period beginning in FY 2000 would be
between 0.4 and 2.9 percent, or 0 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. In the May 7, 1999 proposed rule, based on available
data, we estimated that, for cost reporting periods beginning in FY
2000, the caps on target amounts would be $11,067 for psychiatric
hospitals and hospital units, $20,071 for rehabilitation hospitals and
hospital units, and $39,596 for long-term care hospitals. In this final
rule, based on updated data, we are establishing the caps as follows:
$11,100 for psychiatric hospitals and hospital units, $20,129 for
rehabilitation hospitals and hospital units, and $36,712 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 final rule and in this Addendum. For purposes of this
final 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, 8B, and 10 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
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 3/99 GROUPER V16.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 98 MEDPAR Update 3/99 GROUPER V17.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) July 1999
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) July 1999
Table 10--Percentage Difference in Wage Indexes for Areas That Qualify
for a Wage Index Exception for Excluded Hospitals and Units
[[Page 41558]]
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$2,809.18 $1,141.85 $2,764.70 $1,123.76
------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................ $2,785.40 $1,132.18 $2,785.40 $1,132.18
Puerto Rico..................................... 1,336.54 538.00 1,315.38 529.48
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................... $377.03
Puerto Rico................................................ 174.81
------------------------------------------------------------------------
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
------------------------------------------------------------------------
Case Avg.
Prov. mix hour
index wage
------------------------------------------------------------------------
010001................................................ 1.4595 15.85
010004................................................ 0.9933 15.02
010005................................................ 1.1767 16.26
010006................................................ 1.4579 17.31
010007................................................ 1.1421 14.80
010008................................................ 1.1818 17.65
010009................................................ 1.0941 17.53
010010................................................ 1.0799 15.91
010011................................................ 1.5835 20.63
010012................................................ 1.2614 19.30
010015................................................ 1.0478 18.35
010016................................................ 1.2492 16.13
010018................................................ 0.9696 18.96
010019................................................ 1.2766 15.49
010021................................................ 1.2490 14.63
010022................................................ 0.9597 20.51
010023................................................ 1.6881 16.26
010024................................................ 1.4243 16.03
010025................................................ 1.3513 14.53
010027................................................ 0.8132 14.93
010029................................................ 1.6000 16.41
010031................................................ 1.4175 18.02
010032................................................ 0.8803 12.65
010033................................................ 1.9945 19.68
010034................................................ 1.0473 14.73
010035................................................ 1.2411 17.48
010036................................................ 1.0916 17.29
010038................................................ 1.2337 18.33
010039................................................ 1.6337 18.81
010040................................................ 1.4963 19.10
010043................................................ 1.0500 16.20
010044................................................ 1.0246 17.02
010045................................................ 1.1799 15.01
010046................................................ 1.4713 17.18
010047................................................ 0.9285 16.38
010049................................................ 1.1887 14.48
010050................................................ 1.0755 15.42
010051................................................ 0.8965 9.94
010052................................................ 1.0154 13.86
010053................................................ 1.0508 13.18
010054................................................ 1.1318 17.12
010055................................................ 1.4221 18.19
010056................................................ 1.3283 19.08
010058................................................ 1.0358 12.78
010059................................................ 1.0567 18.19
010061................................................ 1.1098 15.92
010062................................................ 1.0102 13.57
010064................................................ 1.7584 20.90
010065................................................ 1.3234 15.64
010066................................................ 0.9014 12.07
010068................................................ 1.3052 18.74
010069................................................ 1.1329 13.57
010072................................................ 1.0785 14.35
010073................................................ 0.8800 12.83
010078................................................ 1.2901 17.71
010079................................................ 1.1867 16.87
010080................................................ ........ 13.85
010081................................................ 1.6351 16.98
010083................................................ 1.0586 16.21
010084................................................ 1.5089 18.78
010085................................................ 1.3152 18.87
010086................................................ 1.0122 14.93
010087................................................ 1.7288 18.39
010089................................................ 1.1989 16.61
010090................................................ 1.6540 18.11
010091................................................ 0.9933 16.36
010092................................................ 1.4279 16.50
010094................................................ 1.1544 18.56
010095................................................ 1.0456 11.90
010097................................................ 0.8654 12.90
010098................................................ 0.9896 14.28
010099................................................ 1.1725 15.93
010100................................................ 1.2912 15.48
010101................................................ 1.0199 15.42
010102................................................ 0.9314 12.73
010103................................................ 1.8375 19.31
010104................................................ 1.6950 18.10
010108................................................ 1.1528 20.79
010109................................................ 1.0504 14.09
010110................................................ 0.9691 15.91
010112................................................ 1.1495 15.11
010113................................................ 1.6159 17.24
010114................................................ 1.2530 17.26
010115................................................ 0.8495 13.75
010118................................................ 1.2464 16.69
010119................................................ 0.8457 18.17
010120................................................ 0.9886 17.03
010121................................................ 1.2822 15.18
010123................................................ 1.1647 18.16
010124................................................ 1.2264 16.27
010125................................................ 1.0590 14.42
010126................................................ 1.1224 17.64
010127................................................ 1.3140 19.61
010128................................................ 0.9265 12.57
010129................................................ 1.0647 14.43
010130................................................ 1.0418 16.35
010131................................................ 1.3325 17.91
010134................................................ 0.8150 10.78
010137................................................ 1.3106 15.93
010138................................................ 0.9196 12.13
010139................................................ 1.6338 19.95
010143................................................ 1.2282 15.71
010144................................................ 1.4120 17.12
010145................................................ 1.3336 20.75
010146................................................ 1.1894 18.86
010148................................................ 0.9791 14.64
010149................................................ 1.2567 17.08
010150................................................ 1.0438 16.97
010152................................................ 1.2508 17.38
010155................................................ 1.0794 16.70
020001................................................ 1.5235 27.97
020002................................................ 1.0556 26.91
020004................................................ 1.1841 26.40
020005................................................ 0.8955 29.01
[[Page 41559]]
020006................................................ 1.1238 26.77
020007................................................ 0.8205 24.96
020008................................................ 1.0781 30.47
020009................................................ 0.8199 23.18
020010................................................ 0.9473 18.64
020011................................................ 0.9160 29.47
020012................................................ 1.2763 23.92
020013................................................ 0.9595 26.82
020014................................................ 1.1151 24.09
020017................................................ 1.4946 24.97
020018................................................ 0.8973 ......
020019................................................ 0.7991 ......
020021................................................ 0.8011 ......
020024................................................ 1.1106 22.73
020025................................................ 0.9156 27.15
020026................................................ 1.2660 ......
020027................................................ 0.9434 ......
030001................................................ 1.2614 19.87
030002................................................ 1.8069 21.63
030003................................................ 2.2742 23.67
030004................................................ 1.0231 17.73
030006................................................ 1.5269 17.64
030007................................................ 1.2538 18.56
030008................................................ 2.1843 ......
030009................................................ 1.2486 17.93
030010................................................ 1.3867 18.80
030011................................................ 1.4361 20.08
030012................................................ 1.2389 19.42
030013................................................ 1.2741 21.02
030014................................................ 1.5098 19.47
030016................................................ 1.2340 20.56
030017................................................ 1.4178 20.42
030018................................................ 1.8584 18.91
030019................................................ 1.2403 19.92
030022................................................ 1.4895 15.79
030023................................................ 1.4965 22.44
030024 *.............................................. 1.7469 21.67
030025................................................ 0.9555 17.67
030027................................................ 0.9624 17.58
030030................................................ 1.6450 21.62
030033................................................ 1.2353 16.84
030034................................................ 0.9867 19.09
030035................................................ 1.1548 19.72
030036................................................ 1.2810 18.94
030037................................................ 2.0844 21.44
030038................................................ 1.6163 22.08
030040................................................ 1.0766 17.97
030041................................................ 0.8880 17.44
030043................................................ 1.2200 20.77
030044................................................ 0.8787 16.47
030047................................................ 0.8899 19.69
030049................................................ 0.8711 19.09
030054................................................ 0.8646 14.49
030055................................................ 1.2312 18.28
030059................................................ 1.2853 21.71
030060................................................ 1.1435 16.77
030061................................................ 1.6875 17.35
030062................................................ 1.1800 17.48
030064................................................ 1.7662 18.54
030065................................................ 1.8097 19.93
030067................................................ 1.0273 15.62
030068................................................ 1.0246 17.35
030069................................................ 1.3639 19.00
030071................................................ 0.9602 ......
030072................................................ 0.8682 ......
030073................................................ 1.0290 ......
030074................................................ 0.8858 ......
030075................................................ 0.7952 ......
030076................................................ 0.8826 ......
030077................................................ 0.8563 ......
030078................................................ 1.1470 ......
030079................................................ 0.9065 ......
030080................................................ 1.3762 19.99
030083................................................ 1.2775 23.64
030084................................................ 1.1378 ......
030085................................................ 1.4648 17.84
030086................................................ 1.4452 18.50
030087................................................ 1.6802 20.05
030088................................................ 1.3656 19.58
030089................................................ 1.6781 19.90
030092................................................ 1.5831 21.56
030093................................................ 1.4204 19.47
030094................................................ 1.2697 19.48
030095................................................ 1.1371 14.25
030099................................................ 0.9411 18.07
030100................................................ 2.0364 ......
030101................................................ 1.4114 ......
030102................................................ 2.5824 ......
040001................................................ 1.0888 15.57
040002................................................ 1.1552 14.09
040003................................................ 1.1003 14.00
040004................................................ 1.6291 17.29
040005................................................ 1.0368 12.88
040007................................................ 1.6975 19.53
040008................................................ 1.0417 12.70
040010................................................ 1.3432 17.62
040011................................................ 0.9412 12.27
040014................................................ 1.3255 15.39
040015................................................ 1.2147 14.60
040016................................................ 1.6858 17.54
040017................................................ 1.1675 14.95
040018................................................ 1.2212 17.56
040019................................................ 1.0337 25.71
040020................................................ 1.6146 14.81
040021................................................ 1.1844 16.46
040022................................................ 1.4741 16.00
040024................................................ 0.9980 15.73
040025................................................ 0.9100 10.95
040026................................................ 1.5789 18.24
040027................................................ 1.2523 14.54
040028................................................ 1.0074 12.84
040029................................................ 1.2995 17.78
040030................................................ 0.8754 14.15
040032................................................ 0.9633 13.33
040035................................................ 0.9500 11.21
040036................................................ 1.4559 17.91
040037................................................ 1.0687 13.48
040039................................................ 1.2281 13.84
040040................................................ 0.9162 17.43
040041................................................ 1.2619 13.36
040042................................................ 1.2098 14.66
040044................................................ 1.0386 11.44
040045................................................ 1.0121 18.77
040047................................................ 1.0270 16.39
040048................................................ ........ 15.82
040050................................................ 1.1544 11.79
040051................................................ 1.0845 16.28
040053................................................ 1.0708 15.82
040054................................................ 0.9798 15.04
040055................................................ 1.4290 16.10
040058................................................ 1.0566 15.67
040060................................................ 0.9763 11.47
040062................................................ 1.6600 17.28
040064................................................ 1.0495 12.40
040066................................................ 1.0504 17.64
040067................................................ 1.0989 13.49
040069................................................ 1.0278 16.11
040070................................................ 0.9313 15.48
040071................................................ 1.6676 16.30
040072................................................ 1.0377 15.84
040074................................................ 1.2314 17.38
040075................................................ 1.0145 12.75
040076................................................ 1.0802 18.55
040077................................................ 1.0508 12.46
040078................................................ 1.5191 17.86
040080................................................ 1.0065 15.74
040081................................................ 0.8669 10.68
040082................................................ 1.0972 16.51
040084................................................ 1.1085 17.25
040085................................................ 1.1526 15.78
040088................................................ 1.3887 15.67
040090................................................ 0.8950 17.55
040091................................................ 1.1702 17.04
040093................................................ 0.9194 12.90
040100................................................ 1.1477 14.97
040105................................................ 0.9904 14.24
040106................................................ 0.9680 15.40
040107................................................ 1.0685 19.62
040109................................................ 1.1497 13.98
040114................................................ 1.8340 18.31
040116................................................ 1.1343 19.57
040118................................................ 1.4205 17.43
040119................................................ 1.1612 15.38
040124................................................ 1.0612 17.25
040126................................................ 0.9478 11.68
040132................................................ ........ 13.18
040134................................................ 2.7047 ......
040135................................................ 2.3711 ......
050002................................................ 1.4963 27.60
050006................................................ 1.4139 19.53
050007................................................ 1.4840 29.54
050008................................................ 1.4234 25.86
050009................................................ 1.6827 26.25
050013................................................ 1.9903 24.85
050014................................................ 1.2091 24.53
050015................................................ 1.4488 25.38
050016................................................ 1.1522 20.15
050017................................................ 2.0965 23.66
050018................................................ 1.3646 14.66
050021................................................ ........ 28.50
050022................................................ 1.6612 22.96
050024................................................ 1.3214 20.34
050025 *.............................................. 1.7668 22.00
050026................................................ 1.5146 28.69
050028................................................ 1.3702 16.45
050029................................................ 1.4013 23.29
050030................................................ 1.3135 21.01
050032................................................ 1.3391 22.59
050033................................................ 1.4640 24.56
050036................................................ 1.7264 20.47
050038................................................ 1.3454 27.83
050039................................................ 1.6288 22.25
[[Page 41560]]
050040................................................ 1.1955 30.67
050042................................................ 1.2702 22.23
050043................................................ 1.4927 33.23
050045................................................ 1.2716 20.73
050046................................................ 1.1729 31.38
050047................................................ 1.5619 29.44
050051................................................ 1.1199 17.84
050054................................................ 1.1899 19.37
050055................................................ 1.2399 29.09
050056................................................ 1.3404 23.85
050057................................................ 1.5981 21.76
050058................................................ 1.4969 25.73
050060................................................ 1.5506 20.92
050061................................................ 1.4125 23.74
050063................................................ 1.3477 23.07
050065................................................ 1.6835 21.18
050066................................................ 1.3006 21.42
050067................................................ 1.2503 21.30
050068................................................ 1.1029 28.48
050069................................................ 1.6082 29.30
050070................................................ 1.2340 32.60
050071................................................ 1.3229 33.14
050072................................................ 1.3883 32.97
050073................................................ 1.2621 34.61
050074................................................ 0.8073 ......
050075................................................ 1.3460 33.52
050076................................................ 2.0321 33.88
050077................................................ 1.5585 23.30
050078................................................ 1.2960 22.80
050079................................................ 1.4849 34.43
050082................................................ 1.6734 21.70
050084................................................ 1.6102 23.10
050088................................................ 0.9681 24.06
050089................................................ 1.3381 20.02
050090................................................ 1.2652 23.90
050091................................................ 1.0925 22.22
050092................................................ 0.8481 15.38
050093................................................ 1.5646 24.08
050095................................................ ........ 33.38
050096................................................ 1.1459 21.67
050097................................................ 1.5292 22.61
050099................................................ 1.4630 24.29
050100................................................ 1.6425 30.06
050101................................................ 1.3595 30.01
050102................................................ 1.3792 21.29
050103 *.............................................. 1.5724 25.34
050104................................................ 1.4491 25.44
050107................................................ 1.4640 21.76
050108................................................ 1.8389 25.21
050109................................................ ........ 26.48
050110................................................ 1.2148 20.18
050111................................................ 1.2943 21.74
050112................................................ 1.3851 26.29
050113................................................ 1.3172 27.78
050114................................................ 1.3842 25.91
050115................................................ 1.4915 21.05
050116................................................ 1.5226 25.59
050117................................................ 1.3979 20.44
050118................................................ 1.1870 24.00
050121................................................ 1.2882 18.88
050122................................................ 1.5694 ......
050124................................................ 1.2826 23.02
050125................................................ 1.3726 24.04
050126................................................ 1.4571 23.84
050127................................................ 1.2537 19.76
050128................................................ 1.6061 24.18
050129................................................ 1.7541 27.16
050131................................................ 1.2640 29.06
050132................................................ 1.3641 22.91
050133................................................ 1.2717 24.40
050135................................................ 1.4811 27.03
050136................................................ 1.3553 24.43
050137................................................ 1.3023 30.07
050138................................................ 2.0450 37.41
050139................................................ 1.2542 31.38
050140................................................ 1.3201 33.66
050144................................................ 1.4211 25.75
050145................................................ 1.3762 33.06
050146................................................ 1.5826 ......
050148................................................ 1.1126 21.06
050149................................................ 1.4979 23.38
050150................................................ 1.2673 23.48
050152................................................ 1.3291 27.75
050153................................................ 1.6393 29.59
050155................................................ 1.0972 22.94
050158................................................ 1.3019 27.98
050159................................................ 1.3226 25.21
050167................................................ 1.3813 21.68
050168................................................ 1.5382 25.25
050169................................................ 1.4765 24.64
050170................................................ 1.4490 22.20
050172................................................ 1.2543 17.70
050173................................................ 1.3755 23.33
050174................................................ 1.7008 31.21
050175................................................ 1.2707 27.79
050177................................................ 1.1869 20.25
050179................................................ 1.2337 19.29
050180................................................ 1.5831 32.19
050183................................................ 1.2743 19.98
050186................................................ 1.3443 21.91
050188................................................ 1.4374 27.44
050189................................................ 0.9674 23.24
050191................................................ 1.4686 26.73
050192................................................ 1.1474 17.81
050193................................................ 1.1575 23.73
050194................................................ 1.2304 28.27
050195................................................ 1.5638 34.78
050196................................................ 1.2799 16.69
050197................................................ 1.9550 31.45
050204................................................ 1.5274 24.39
050205................................................ 1.2839 21.15
050207................................................ 1.2607 20.86
050211................................................ 1.3187 31.22
050213................................................ 1.5919 20.73
050214................................................ 1.5454 20.87
050215................................................ 1.5686 28.41
050217................................................ 1.2859 19.89
050219................................................ 1.1417 25.47
050222................................................ 1.5169 27.07
050224................................................ 1.5831 23.79
050225................................................ 1.5688 20.80
050226................................................ 1.3277 26.93
050228................................................ 1.3226 30.38
050230................................................ 1.4125 25.36
050231................................................ 1.6438 25.58
050232................................................ 1.5691 23.38
050233................................................ ........ 31.40
050234................................................ 1.1501 28.52
050235................................................ 1.5560 25.86
050236................................................ 1.5100 26.27
050238................................................ 1.5300 24.00
050239................................................ 1.5979 20.41
050240................................................ 1.5284 25.25
050241................................................ 1.1379 27.22
050242................................................ 1.4436 30.14
050243................................................ 1.5323 22.91
050245................................................ 1.5075 24.40
050248................................................ 1.2025 27.42
050251................................................ 1.1079 18.50
050253................................................ 1.4192 20.07
050254................................................ 1.2000 19.69
050256................................................ 1.7675 23.53
050257................................................ 0.9509 19.59
050260................................................ 0.9690 23.52
050261................................................ 1.2104 20.45
050262................................................ 1.8179 29.01
050264................................................ 1.3472 29.45
050267................................................ 1.6945 24.75
050270................................................ 1.3631 23.73
050272................................................ 1.3984 21.44
050274................................................ 0.9467 21.19
050276................................................ 1.1734 28.51
050277................................................ 1.4821 22.31
050278................................................ 1.5187 23.84
050279................................................ 1.2881 21.06
050280................................................ 1.6532 24.43
050281................................................ 1.3916 18.59
050282................................................ 1.3212 24.46
050283................................................ 1.5054 27.88
050286................................................ 0.9172 17.80
050289................................................ 1.7326 26.72
050290................................................ 1.6720 26.37
050291................................................ 1.1953 26.49
050292................................................ 1.1088 22.49
050293................................................ 1.0656 19.18
050295................................................ 1.4570 20.74
050296................................................ 1.2166 25.32
050298................................................ 1.3348 20.52
050299................................................ 1.3248 25.77
050300................................................ 1.4160 22.74
050301................................................ 1.2329 26.03
050302................................................ ........ 29.20
050305................................................ 1.5886 32.71
050307................................................ 1.2758 27.98
050308................................................ 1.5082 28.40
050309................................................ 1.2826 24.40
050310................................................ ........ 20.62
050312................................................ 1.9732 23.79
050313................................................ 1.1561 23.10
050315................................................ 1.3435 21.92
050317................................................ ........ 19.45
050320................................................ 1.2358 30.60
050324................................................ 2.0041 26.27
050325................................................ 1.2290 23.24
050327................................................ 1.6638 22.85
050328................................................ ........ 23.19
050329................................................ 1.2988 21.41
050331................................................ 1.3506 25.53
050333................................................ 1.0612 20.15
050334................................................ 1.7488 32.02
050335................................................ 1.4579 20.20
050336................................................ 1.3568 20.10
[[Page 41561]]
050342................................................ 1.2515 19.35
050343................................................ 0.9701 17.34
050348................................................ 1.8021 20.75
050349................................................ 0.8875 15.05
050350................................................ 1.4042 25.07
050351................................................ 1.4941 24.69
050352................................................ 1.3148 23.59
050353................................................ 1.6191 23.25
050355................................................ 0.8391 17.16
050357................................................ 1.3422 23.64
050359................................................ 1.2474 20.40
050360................................................ 1.4310 31.76
050366................................................ 1.3326 21.34
050367................................................ 1.2594 29.48
050369................................................ 1.3034 24.26
050373................................................ 1.3971 26.65
050376................................................ 1.4232 25.30
050377................................................ 1.0200 25.64
050378................................................ 1.0934 22.24
050379................................................ 1.0197 15.50
050380................................................ 1.6047 30.58
050382................................................ 1.3597 26.15
050385................................................ 1.3419 25.92
050388................................................ 0.8725 13.79
050390................................................ 1.1965 22.57
050391................................................ 1.3438 22.49
050392................................................ 0.9370 21.93
050393................................................ 1.4352 23.14
050394................................................ 1.5741 22.24
050396................................................ 1.6444 23.63
050397................................................ 0.9367 20.77
050401................................................ 1.1055 17.78
050404................................................ 1.0664 19.28
050406................................................ 1.0245 16.89
050407................................................ 1.2842 30.12
050410................................................ 1.0668 16.47
050411................................................ 1.3582 32.24
050414................................................ 1.2992 24.42
050417................................................ 1.3197 21.89
050419................................................ 1.3788 23.12
050420................................................ 1.3062 22.68
050421................................................ 1.2343 ......
050423................................................ 1.0112 23.33
050424................................................ 1.8400 23.78
050425................................................ 1.2315 33.69
050426................................................ 1.3898 23.71
050427................................................ 0.9468 20.07
050430................................................ 1.0003 21.34
050432................................................ 1.5198 21.50
050433................................................ 0.9711 16.80
050434................................................ 1.0631 15.63
050435................................................ 1.1647 32.99
050436................................................ 1.0075 16.36
050438................................................ 1.7349 24.08
050440................................................ 1.2722 21.11
050441................................................ 1.9397 28.71
050443................................................ 0.8705 16.43
050444................................................ 1.3224 24.67
050446................................................ 0.8088 20.54
050447................................................ 1.0850 18.42
050448................................................ 1.1055 20.08
050449................................................ 1.2871 22.18
050454 *.............................................. 1.7729 28.69
050455................................................ 1.7949 19.92
050456................................................ 1.2213 17.62
050457................................................ 1.9129 31.25
050459................................................ 1.5220 37.09
050464................................................ 1.7089 22.31
050468................................................ 1.5589 23.17
050469................................................ 1.1499 23.44
050470................................................ 1.1391 17.03
050471................................................ 1.8969 24.29
050476................................................ 1.3686 23.14
050477................................................ 1.4367 27.78
050478................................................ 0.9911 23.05
050481................................................ 1.3949 26.83
050482................................................ 1.0569 16.93
050483................................................ 2.2575 21.60
050485................................................ 1.6066 23.19
050486................................................ ........ 24.50
050488................................................ 1.3257 32.86
050491................................................ 1.2006 25.10
050492................................................ 1.4183 21.42
050494................................................ 1.2386 25.41
050496................................................ 1.7595 33.02
050497................................................ 0.8258 ......
050498................................................ 1.2296 24.84
050502................................................ 1.7271 22.63
050503................................................ 1.3477 23.59
050506................................................ 1.3621 21.22
050510................................................ 1.2784 33.46
050512................................................ 1.4429 34.31
050515................................................ 1.3439 35.04
050516................................................ 1.5017 25.19
050517................................................ 1.2038 20.37
050522................................................ 1.1593 31.73
050523................................................ 1.2442 28.42
050526................................................ 1.2943 26.92
050528................................................ 1.1883 18.69
050531................................................ 1.1101 20.73
050534................................................ 1.2834 23.30
050535................................................ 1.5140 24.23
050537................................................ 1.3698 22.21
050539................................................ 1.3269 23.25
050541................................................ 1.5646 34.62
050542................................................ 0.9786 17.85
050543................................................ 0.8445 23.04
050545................................................ 0.7658 27.57
050546................................................ 0.6961 27.76
050547................................................ 0.9008 27.08
050548................................................ ........ 26.59
050549................................................ 1.6034 27.91
050550................................................ 1.3697 25.75
050551................................................ 1.3532 24.05
050552................................................ 1.2766 22.87
050557................................................ 1.5203 22.14
050559................................................ 1.2865 24.67
050561................................................ 1.2133 33.93
050564................................................ 1.3237 24.51
050565................................................ 1.3123 22.88
050566................................................ 0.9219 18.33
050567................................................ 1.5570 24.23
050568................................................ 1.3420 20.52
050569................................................ 1.2025 24.94
050570................................................ 1.6497 24.50
050571................................................ 1.3946 24.37
050573................................................ 1.5647 25.14
050575................................................ 1.1467 ......
050577................................................ 1.3600 20.52
050578................................................ 1.2666 28.91
050579................................................ 1.4322 30.07
050580................................................ 1.2849 23.92
050581................................................ 1.4507 23.57
050583................................................ 1.6163 23.36
050584................................................ 1.2401 23.16
050585................................................ 1.2561 26.50
050586................................................ 1.3532 23.84
050588................................................ 1.2801 30.39
050589................................................ 1.2395 24.35
050590................................................ 1.3227 ......
050591................................................ 1.3156 22.32
050592................................................ 1.2663 26.05
050594................................................ 1.6277 22.78
050597................................................ 1.2260 23.18
050598................................................ 1.3410 28.11
050599................................................ 1.5942 26.32
050601................................................ 1.6465 32.87
050603................................................ 1.4208 22.75
050604................................................ 1.4564 33.32
050607................................................ ........ 24.10
050608................................................ 1.2793 16.15
050609................................................ 1.4917 31.93
050613................................................ 1.1189 23.48
050615................................................ 1.5453 23.70
050616................................................ 1.3449 22.80
050618................................................ 1.0867 21.70
050623................................................ 1.5638 30.32
050624................................................ 1.3297 22.34
050625................................................ 1.6305 24.35
050630................................................ 1.2762 24.10
050633................................................ 1.2825 21.98
050635................................................ ........ 37.85
050636................................................ 1.4239 20.83
050638................................................ 1.1491 23.63
050641................................................ 1.2971 21.36
050643................................................ 0.9604 ......
050644................................................ 1.0737 23.12
050660................................................ 1.4966 ......
050661................................................ ........ 20.48
050662................................................ 0.8151 28.29
050663................................................ 1.1758 23.71
050667................................................ 1.0967 24.11
050668................................................ 1.0944 39.90
050670................................................ 0.7555 21.88
050674................................................ 1.2425 36.24
050675................................................ 2.2195 15.84
050676................................................ 1.0018 17.53
050677................................................ 1.3679 33.71
050678................................................ 1.2889 22.66
050680................................................ 1.1178 27.32
050682................................................ 0.9234 17.97
050684................................................ 1.2409 21.81
050685................................................ 1.1904 32.13
050686................................................ 1.2866 33.25
050688................................................ 1.1936 30.00
050689................................................ 1.4920 34.19
050690................................................ 1.4168 33.83
050693................................................ 1.3155 33.30
050694................................................ 1.3866 22.57
050695................................................ 1.0607 23.52
050696................................................ 2.1060 26.41
050697................................................ 1.3204 21.47
[[Page 41562]]
050699................................................ 0.5913 28.48
050700................................................ ........ 28.45
050701................................................ 1.3166 27.62
050702................................................ ........ 12.25
050704................................................ 1.0855 20.76
050707................................................ 0.9714 27.51
050708................................................ 1.4500 21.91
050709................................................ 1.2519 19.42
050710................................................ 1.3390 26.81
050713................................................ 0.7909 15.30
050714................................................ 1.3510 ......
050715................................................ ........ 19.12
050717................................................ 1.2647 ......
050718................................................ 0.7579 ......
050719................................................ 3.1984 ......
050720................................................ 0.9044 ......
060001................................................ 1.6835 20.59
060003................................................ 1.2708 19.32
060004................................................ 1.1987 21.79
060006................................................ 1.2571 17.86
060007................................................ 1.1650 16.38
060008................................................ 1.0843 17.09
060009................................................ 1.4985 21.18
060010................................................ 1.6674 22.72
060011................................................ 1.3925 21.97
060012................................................ 1.3814 19.77
060013................................................ 1.3217 19.14
060014................................................ 1.8153 20.53
060015................................................ 1.6320 23.57
060016................................................ 1.1638 15.96
060018................................................ 1.2867 21.86
060020................................................ 1.6130 17.73
060022................................................ 1.5677 19.65
060023................................................ 1.6323 19.65
060024................................................ 1.7015 22.83
060027................................................ 1.6925 21.67
060028................................................ 1.5331 22.25
060029................................................ 0.8925 21.41
060030................................................ 1.3542 20.03
060031................................................ 1.5383 19.40
060032................................................ 1.4782 22.37
060033................................................ 1.1398 13.82
060034................................................ 1.5846 21.41
060036................................................ 1.1376 19.24
060037................................................ 1.0079 14.05
060038................................................ 0.9440 14.31
060041................................................ 0.9246 14.83
060042................................................ 1.0356 20.08
060043................................................ 0.8801 13.05
060044................................................ 1.1681 22.53
060046................................................ 1.0302 20.44
060047................................................ 0.9655 15.12
060049................................................ 1.3171 20.64
060050................................................ 1.2512 16.80
060052................................................ 1.0404 12.55
060053................................................ 1.0148 14.94
060054................................................ 1.4104 19.39
060056................................................ 0.9051 17.05
060057................................................ 1.0273 23.38
060058................................................ 0.9425 16.91
060060................................................ 0.9200 14.89
060062................................................ 0.8628 14.94
060063................................................ ........ 15.09
060064................................................ 1.4833 20.93
060065................................................ 1.2913 24.30
060066................................................ 0.9930 14.07
060068................................................ ........ 19.64
060070................................................ 1.1250 16.58
060071................................................ 1.2078 16.95
060073................................................ 0.9583 15.84
060075................................................ 1.2425 22.85
060076................................................ 1.4325 19.29
060085................................................ 0.8869 13.48
060087................................................ ........ 21.03
060088................................................ 0.9983 16.67
060090................................................ 0.8997 14.51
060096................................................ 1.1067 23.12
060100................................................ 1.5321 22.00
060103................................................ 1.3211 22.34
060104................................................ 1.2351 22.30
060107................................................ 1.1955 13.64
060108................................................ 0.4789 ......
060109................................................ 1.1185 ......
070001................................................ 1.7614 26.51
070002................................................ 1.8336 25.46
070003................................................ 1.1215 26.09
070004................................................ 1.2043 23.27
070005................................................ 1.4436 25.57
070006................................................ 1.3881 28.71
070007................................................ 1.3524 27.19
070008................................................ 1.2506 26.03
070009................................................ 1.2685 23.47
070010................................................ 1.6992 25.94
070011................................................ 1.3820 23.96
070012................................................ 1.1724 25.10
070015................................................ 1.3890 25.33
070016................................................ 1.4259 26.30
070017................................................ 1.3718 24.80
070018................................................ 1.3684 28.88
070019................................................ 1.1838 24.70
070020................................................ 1.3222 23.72
070021................................................ 1.2362 26.52
070022................................................ 1.8643 25.08
070024................................................ 1.3255 25.15
070025................................................ 1.8686 25.41
070026................................................ ........ 18.79
070027................................................ 1.3113 23.64
070028................................................ 1.5522 24.69
070029................................................ 1.3352 22.75
070030................................................ 1.2883 24.97
070031................................................ 1.2420 21.66
070033................................................ 1.4115 28.81
070034................................................ 1.3893 29.12
070035................................................ 1.4205 23.06
070036................................................ 1.7251 28.95
070038................................................ 0.7729 ......
070039................................................ 0.9555 21.78
080001................................................ 1.7133 25.28
080002................................................ ........ 15.60
080003................................................ 1.3835 22.40
080004................................................ 1.2651 19.77
080005................................................ ........ 14.43
080006................................................ 1.3003 22.26
080007................................................ 1.4176 20.38
090001................................................ 1.6034 25.89
090002................................................ 1.3475 19.70
090003................................................ 1.3718 28.61
090004................................................ 1.7978 24.43
090005................................................ 1.3706 24.88
090006................................................ 1.3152 20.08
090007................................................ 1.3040 21.66
090008................................................ 1.5064 21.60
090010................................................ 1.0721 15.87
090011................................................ 2.1194 27.37
100001................................................ 1.5307 17.69
100002................................................ 1.4390 21.32
100004................................................ 1.0119 15.25
100006................................................ 1.6160 20.63
100007................................................ 1.8871 21.72
100008................................................ 1.5830 20.72
100009................................................ 1.4671 24.29
100010................................................ 1.4977 21.91
100012................................................ 1.6382 18.52
100014................................................ 1.4823 19.83
100015................................................ 1.4805 18.24
100017................................................ 1.5923 17.77
100018................................................ 1.5493 20.84
100019................................................ 1.5572 19.81
100020................................................ 1.3926 26.18
100022................................................ 1.7978 25.89
100023................................................ 1.3578 21.11
100024................................................ 1.3497 20.78
100025................................................ 1.7580 19.12
100026................................................ 1.5873 20.76
100027................................................ 1.0231 12.94
100028................................................ 1.2105 19.75
100029................................................ 1.3375 19.18
100030................................................ 1.2542 18.82
100032................................................ 1.8533 19.32
100034................................................ 1.7580 18.23
100035................................................ 1.5894 19.58
100038................................................ 1.6636 24.78
100039................................................ 1.5287 20.25
100040................................................ 1.7501 18.64
100043................................................ 1.3307 17.52
100044................................................ 1.3922 21.14
100045................................................ 1.3923 20.77
100046................................................ 1.4279 21.21
100047................................................ 1.8496 18.87
100048................................................ 0.9391 13.50
100049................................................ 1.2653 18.56
100050................................................ 1.1494 16.60
100051................................................ 1.2391 18.84
100052................................................ 1.3875 16.19
100053................................................ 1.2128 18.71
100054................................................ 1.2776 18.19
100055................................................ 1.3755 17.62
100056................................................ 1.4973 23.65
100057................................................ 1.3595 18.75
100060................................................ 1.8341 22.39
100061................................................ 1.4541 21.79
100062................................................ 1.7297 17.96
100063................................................ 1.1596 16.23
100067................................................ 1.3589 17.40
100068................................................ 1.3600 18.65
100069................................................ 1.2996 16.14
100070................................................ 1.4348 20.33
100071................................................ 1.2324 16.48
100072................................................ 1.2519 19.22
100073................................................ 1.7170 18.16
100075................................................ 1.5967 18.05
100076................................................ 1.2999 16.25
[[Page 41563]]
100077................................................ 1.3907 19.62
100078................................................ 1.0296 18.28
100079................................................ 1.3325 ......
100080................................................ 1.6004 21.16
100081................................................ 1.1059 13.96
100082................................................ 1.4981 19.80
100084................................................ 1.3484 20.40
100085................................................ 1.4397 21.08
100086................................................ 1.2337 21.16
100087................................................ 1.8332 23.12
100088................................................ 1.6560 20.06
100090................................................ 1.3796 17.88
100092................................................ 1.5762 18.19
100093................................................ 1.5951 16.63
100098................................................ 1.0984 19.03
100099................................................ 1.2207 15.30
100102................................................ 1.0153 19.33
100103................................................ 0.9374 18.10
100105................................................ 1.4538 21.50
100106................................................ 1.0262 19.31
100107................................................ 1.3128 18.01
100108................................................ 0.9979 11.47
100109................................................ 1.3846 22.17
100110................................................ 1.3687 19.64
100112................................................ 0.9703 9.77
100113................................................ 1.9526 22.26
100114................................................ 1.3378 23.45
100117................................................ 1.1904 18.86
100118................................................ 1.2978 19.76
100121................................................ 1.1778 19.34
100122................................................ 1.2065 18.06
100124................................................ 1.2961 19.05
100125................................................ 1.2709 17.33
100126................................................ 1.4682 18.09
100127................................................ 1.6587 19.87
100128................................................ 2.2076 21.37
100129................................................ 1.3074 18.57
100130................................................ 1.1759 19.10
100131................................................ 1.3440 22.17
100132................................................ 1.2920 16.90
100134................................................ 0.9738 13.47
100135................................................ 1.5672 17.48
100137................................................ 1.2758 19.05
100138................................................ 1.0055 11.01
100139................................................ 1.0894 15.64
100140................................................ 1.2173 17.35
100142................................................ 1.2261 18.68
100144................................................ 1.1622 15.02
100145................................................ ........ 19.11
100146................................................ 0.9697 17.87
100147................................................ 1.0080 14.68
100150................................................ 1.3244 21.02
100151................................................ 1.7687 19.40
100154................................................ 1.5832 19.85
100156................................................ 1.1101 17.13
100157................................................ 1.5609 21.03
100159................................................ 0.9570 16.38
100160................................................ 1.2026 21.63
100161................................................ 1.6995 21.50
100162................................................ 1.3955 19.87
100165................................................ 1.1535 18.57
100166................................................ 1.4349 20.42
100167................................................ 1.3548 21.81
100168................................................ 1.3372 20.13
100169................................................ 1.7623 20.78
100170................................................ 1.4159 15.12
100172................................................ 1.4335 15.18
100173................................................ 1.6528 17.34
100174................................................ 1.3768 20.51
100175................................................ 1.1543 17.82
100176................................................ 2.0764 24.70
100177................................................ 1.2977 22.00
100179................................................ 1.7103 20.91
100180................................................ 1.4415 18.48
100181................................................ 1.1065 24.57
100183................................................ 1.1888 20.86
100187................................................ 1.4299 20.69
100189................................................ 1.3286 21.01
100191................................................ 1.3182 18.47
100199................................................ 1.3519 23.37
100200................................................ 1.2409 22.26
100203................................................ ........ 18.86
100204................................................ 1.6272 20.20
100206................................................ 1.3739 20.35
100207................................................ ........ 15.92
100208................................................ 1.3673 20.83
100209................................................ 1.4791 19.73
100210................................................ 1.5718 19.18
100211................................................ 1.3991 25.53
100212................................................ 1.6224 25.34
100213................................................ 1.5100 19.12
100217................................................ 1.2751 19.87
100220................................................ 1.6355 19.91
100221................................................ 1.8110 22.25
100222................................................ 0.9440 22.19
100223................................................ 1.4651 18.76
100224................................................ 1.3349 24.70
100225................................................ 1.3371 20.64
100226................................................ 1.3508 24.86
100228................................................ 1.2825 23.70
100229................................................ 1.3326 18.21
100230................................................ 1.3523 20.60
100231................................................ 1.6815 17.40
100232................................................ 1.2511 17.32
100234................................................ 1.2587 21.58
100235................................................ ........ 17.66
100236................................................ 1.3925 21.81
100237................................................ 2.1893 22.93
100238................................................ 1.5454 17.63
100239................................................ 1.4287 19.76
100240................................................ 1.0888 17.93
100241................................................ 0.8994 13.83
100242................................................ 1.4298 17.12
100243................................................ 1.4071 20.38
100244................................................ 1.3741 17.41
100246................................................ 1.3686 21.22
100248................................................ 1.5873 21.54
100249................................................ 1.3084 19.02
100252................................................ 1.2005 17.87
100253................................................ 1.4323 20.60
100254................................................ 1.5401 20.91
100255................................................ 1.2559 21.02
100256................................................ 2.0104 23.56
100258................................................ 1.6901 21.88
100259................................................ 1.3409 19.86
100260................................................ 1.4570 21.22
100262................................................ 1.3448 19.59
100263................................................ ........ 16.90
100264................................................ 1.3620 17.61
100265................................................ 1.2932 19.86
100266................................................ 1.3567 17.73
100267................................................ 1.3056 17.10
100268................................................ 1.1952 23.59
100269................................................ 1.4345 21.20
100270................................................ 1.0181 19.86
100271................................................ 1.7715 19.92
100275................................................ 1.3944 21.33
100276................................................ 1.2371 21.98
100277................................................ 1.0333 16.14
100279................................................ 1.2721 23.02
100280................................................ 1.2951 16.58
100281................................................ 1.2795 22.02
100282................................................ 1.0837 19.77
100284................................................ 1.0855 ......
110001................................................ 1.2552 18.06
110002................................................ 1.2532 17.37
110003................................................ 1.3637 16.91
110004................................................ 1.3569 18.95
110005................................................ 1.1963 19.26
110006................................................ 1.4201 20.13
110007................................................ 1.6114 23.50
110008................................................ 1.2419 18.26
110009................................................ 1.1355 14.82
110010................................................ 2.1768 24.55
110011................................................ 1.1631 18.28
110013................................................ 1.0596 16.03
110014................................................ 0.9442 16.12
110015................................................ 1.1403 19.48
110016................................................ 1.2284 15.30
110017................................................ 0.9311 10.54
110018................................................ 1.1969 21.04
110020................................................ 1.1913 18.53
110023................................................ 1.3377 18.65
110024................................................ 1.3651 19.79
110025................................................ 1.3872 18.65
110026................................................ 1.1354 16.14
110027................................................ 1.1200 14.68
110028................................................ 1.7799 19.89
110029................................................ 1.3551 20.05
110030................................................ 1.2989 17.68
110031................................................ 1.2252 21.58
110032................................................ 1.2518 16.19
110033................................................ 1.4207 21.41
110034................................................ 1.5887 18.19
110035................................................ 1.3910 21.17
110036................................................ 1.8557 24.42
110038................................................ 1.4440 16.38
110039................................................ 1.4173 20.77
110040................................................ 1.0663 16.40
110041................................................ 1.1827 16.69
110042................................................ 1.1533 20.65
110043................................................ 1.8094 17.22
110044................................................ 1.1898 19.60
110045................................................ 1.1386 19.94
110046................................................ 1.2456 19.23
110048................................................ 1.2372 15.65
110049................................................ 1.0992 14.21
110050................................................ 1.1823 18.75
110051................................................ 1.0253 15.75
110052................................................ ........ 15.06
110054................................................ 1.3647 19.27
110056................................................ 1.0854 16.50
[[Page 41564]]
110059................................................ 1.2176 17.70
110061................................................ 1.0960 13.72
110062................................................ 0.9082 12.21
110063................................................ 1.0542 17.97
110064................................................ 1.4891 18.34
110065................................................ 1.0304 13.32
110066................................................ 1.4455 20.65
110069................................................ 1.2576 18.35
110070................................................ 1.1398 18.23
110071................................................ 1.0981 14.89
110072................................................ 0.9710 12.43
110073................................................ 1.1423 15.14
110074................................................ 1.5078 20.76
110075................................................ 1.3221 17.01
110076................................................ 1.4652 20.44
110078................................................ 1.7591 24.71
110079................................................ 1.4560 20.14
110080................................................ 1.3568 23.43
110082................................................ 2.0994 22.01
110083................................................ 1.7625 21.36
110086................................................ 1.2841 14.98
110087................................................ 1.3556 20.54
110089................................................ 1.2027 18.58
110091................................................ 1.2778 21.38
110092................................................ 1.0882 15.09
110093................................................ 0.9940 14.80
110094................................................ 0.9912 13.87
110095................................................ 1.3528 15.95
110096................................................ 1.0800 16.32
110097................................................ 1.0625 15.62
110098................................................ 0.9868 14.01
110100................................................ 1.0558 20.38
110101................................................ 1.1014 11.73
110103................................................ 0.9292 11.94
110104................................................ 1.0957 15.32
110105................................................ 1.3084 16.52
110107................................................ 1.8959 17.39
110108................................................ 0.9495 15.14
110109................................................ 1.1092 16.37
110111................................................ 1.2038 17.32
110112................................................ 0.9910 19.13
110113................................................ 1.0478 15.19
110114................................................ 1.0443 15.13
110115................................................ 1.7515 24.83
110118................................................ 1.1342 15.40
110120................................................ 1.0378 15.19
110121................................................ 1.2814 15.58
110122................................................ 1.3852 18.85
110124................................................ 1.2083 17.13
110125................................................ 1.2563 17.33
110127................................................ 0.8834 13.76
110128................................................ 1.1927 18.97
110129................................................ 1.6606 18.12
110130................................................ 1.0077 13.08
110132................................................ 1.1467 15.02
110134................................................ 0.9641 11.56
110135................................................ 1.3364 17.08
110136................................................ 1.1043 16.17
110140................................................ 1.0432 17.88
110141................................................ 0.9978 12.51
110142................................................ 0.9537 12.30
110143................................................ 1.4324 21.69
110144................................................ 1.0701 17.98
110146................................................ 1.0869 17.61
110149................................................ 1.1792 22.23
110150................................................ 1.4100 18.77
110152................................................ 1.0430 14.77
110153................................................ 1.0935 18.69
110154................................................ 0.9773 14.81
110155................................................ 1.1373 17.14
110156................................................ 1.0500 15.34
110161................................................ 1.3183 20.87
110162................................................ 0.7522 ......
110163................................................ 1.4626 18.20
110164................................................ 1.4197 19.49
110165................................................ 1.4296 19.00
110166................................................ 1.4485 19.85
110168................................................ 1.6662 19.82
110169................................................ 1.2028 18.72
110171................................................ 1.6129 20.09
110172................................................ 1.3551 25.44
110174................................................ 0.9161 14.30
110176................................................ 3.7291 22.40
110177................................................ 1.5099 19.59
110178................................................ ........ 16.85
110179................................................ 1.1506 20.52
110181................................................ 0.9051 13.72
110183................................................ 1.3138 21.18
110184................................................ 1.2424 20.95
110185................................................ 1.1859 16.25
110186................................................ 1.2579 17.34
110187................................................ 1.2755 21.45
110188................................................ 1.3546 20.05
110189................................................ 1.1719 18.86
110190................................................ 1.0646 19.43
110191................................................ 1.3087 19.11
110192................................................ 1.4455 20.77
110193................................................ 1.2441 18.78
110194................................................ 0.8928 15.09
110195................................................ 1.0992 10.52
110198................................................ 1.2874 26.19
110200................................................ 1.8858 17.21
110201................................................ 1.5098 19.24
110203................................................ 0.9319 20.30
110204................................................ 0.8239 20.57
110205................................................ 1.0578 26.12
110207................................................ 1.0141 12.87
110208................................................ 0.9593 14.89
110209................................................ 0.7100 20.46
110211................................................ 0.9611 21.82
110212................................................ 1.0031 12.66
110213................................................ ........ 13.20
110215................................................ 1.0915 ......
110216................................................ 2.1653 ......
110217................................................ 2.8336 ......
120001 *.............................................. 1.8210 26.71
120002................................................ 1.2129 24.38
120003................................................ 1.1495 23.85
120004................................................ 1.2588 24.05
120005................................................ 1.2449 20.54
120006................................................ 1.2730 23.72
120007................................................ 1.7318 23.27
120009................................................ 0.9876 19.02
120010 *.............................................. 1.8326 25.40
120011................................................ 1.3630 33.55
120012................................................ 0.8391 22.52
120014................................................ 1.2760 24.05
120015................................................ 1.0355 29.07
120016................................................ 1.0574 29.41
120018................................................ 1.2117 25.61
120019................................................ 1.3192 21.92
120021................................................ 0.8937 19.42
120022 *.............................................. 1.6843 17.93
120024................................................ 1.0727 22.28
120025................................................ ........ 19.02
120026................................................ 1.2648 23.22
120027................................................ 1.4048 24.55
120028................................................ 1.2481 23.49
130001................................................ 0.9681 24.95
130002................................................ 1.3266 16.19
130003................................................ 1.3394 19.95
130005................................................ 1.4416 20.17
130006................................................ 1.8354 18.87
130007................................................ 1.6730 19.84
130008................................................ 0.9590 12.92
130009................................................ 0.9302 18.30
130010................................................ 0.8926 21.43
130011................................................ 1.2859 19.08
130012................................................ 0.9911 22.62
130013................................................ 1.3306 19.22
130014................................................ 1.3247 17.98
130015................................................ 0.8768 15.27
130016................................................ 1.0211 17.00
130017................................................ 1.1066 16.88
130018................................................ 1.6255 17.97
130019................................................ 1.1213 17.23
130021................................................ 0.9692 12.26
130022................................................ 1.2150 19.50
130024................................................ 1.1595 18.38
130025................................................ 1.0955 15.27
130026................................................ 1.1725 20.55
130027................................................ 0.9334 20.70
130028................................................ 1.2849 18.21
130029................................................ 1.0697 20.32
130030................................................ 0.8448 18.40
130031................................................ 1.0229 17.65
130034................................................ 1.0325 18.82
130035................................................ 1.1048 20.47
130036................................................ 1.3938 13.79
130037................................................ 1.3059 17.74
130043................................................ 0.9589 16.07
130044................................................ 0.9748 13.18
130045................................................ 0.9802 16.47
130048................................................ 0.9813 15.09
130049................................................ 1.2324 20.39
130054................................................ 0.9573 17.78
130056................................................ 0.8508 15.66
130058................................................ ........ 17.75
130060................................................ 1.2887 20.85
130061................................................ 1.2950 16.78
130062................................................ 0.7200 15.11
130063................................................ 1.4979 ......
140001................................................ 1.2255 15.44
140002................................................ 1.2571 19.26
140003................................................ 1.0026 18.00
140004................................................ 1.1707 17.52
140005................................................ 0.9673 10.87
140007................................................ 1.4692 22.40
140008................................................ 1.4670 21.28
140010................................................ 1.3723 25.22
140011................................................ 1.2034 17.28
140012................................................ 1.2770 19.44
[[Page 41565]]
140013................................................ 1.5752 17.35
140014................................................ 1.1751 20.76
140015................................................ 1.2854 15.02
140016................................................ 1.0294 12.54
140018................................................ 1.2556 21.41
140019................................................ 1.1123 15.34
140024................................................ 0.9557 14.67
140025................................................ 1.0826 16.95
140026................................................ 1.2234 15.96
140027................................................ 1.2694 17.50
140029................................................ 1.3385 21.03
140030................................................ 1.8214 22.44
140031................................................ 1.2008 15.94
140032................................................ 1.3345 17.34
140033................................................ 1.2874 22.56
140034................................................ 1.1851 19.15
140035................................................ 1.0002 13.00
140036................................................ 1.2407 17.04
140037................................................ 1.0383 12.50
140038................................................ 1.1029 17.61
140040................................................ 1.2581 16.25
140041................................................ 1.1609 17.28
140042................................................ 1.0170 15.61
140043................................................ 1.1892 18.95
140045................................................ 1.0315 20.65
140046................................................ 1.3045 16.46
140047................................................ 1.0950 16.33
140048................................................ 1.3056 20.58
140049................................................ 1.6537 21.59
140051................................................ 1.5128 20.85
140052................................................ 1.3027 19.60
140053................................................ 2.0158 17.82
140054................................................ 1.3339 26.15
140055................................................ 1.0225 14.80
140058................................................ 1.2340 17.27
140059................................................ 1.1394 15.39
140061................................................ 1.0953 15.96
140062................................................ 1.2457 27.09
140063................................................ 1.4375 22.39
140064................................................ 1.3249 19.25
140065................................................ 1.4610 23.16
140066................................................ 1.1773 16.17
140067................................................ 1.8177 18.40
140068................................................ 1.2883 18.87
140069................................................ 1.0457 16.15
140070................................................ 1.2636 19.30
140074................................................ 1.0760 19.01
140075................................................ 1.3671 22.51
140077................................................ 1.2557 16.64
140079................................................ 1.2639 21.92
140080................................................ 1.5815 21.00
140081................................................ 1.0826 15.51
140082................................................ 1.3675 22.62
140083................................................ 1.2487 18.13
140084................................................ 1.2529 20.01
140086................................................ 1.1147 17.37
140087................................................ 1.3481 18.36
140088................................................ 1.7136 24.26
140089................................................ 1.2745 17.21
140090................................................ 1.5324 23.59
140091................................................ 1.9057 20.70
140093................................................ 1.1687 19.15
140094................................................ 1.3422 20.61
140095................................................ 1.4016 21.54
140097................................................ 0.9525 16.90
140100................................................ 1.3286 19.06
140101................................................ 1.2240 26.09
140102................................................ 1.0445 15.08
140103................................................ 1.4231 17.86
140105................................................ 1.2926 20.91
140107................................................ 1.0113 12.76
140108................................................ 1.3335 28.60
140109................................................ 1.1446 15.47
140110................................................ 1.2400 18.81
140112................................................ 1.1563 16.24
140113................................................ 1.5588 17.92
140114................................................ 1.3342 20.48
140115 *.............................................. 1.3041 20.09
140116................................................ 1.2341 21.83
140117................................................ 1.5614 19.64
140118................................................ 1.7249 23.08
140119................................................ 1.7816 26.50
140120................................................ 1.3740 14.84
140121................................................ 1.3607 9.53
140122................................................ 1.5542 23.75
140124................................................ 1.1024 26.97
140125................................................ 1.3478 17.10
140127................................................ 1.4164 19.42
140128................................................ 1.0296 17.67
140129................................................ 1.1659 15.25
140130................................................ 1.2488 23.77
140132................................................ 1.4905 23.04
140133................................................ 1.4025 19.91
140135................................................ 1.2759 17.69
140137................................................ 1.0383 16.51
140138................................................ 1.0650 14.59
140139................................................ 1.1039 16.58
140140................................................ 1.1395 15.30
140141................................................ 1.2644 15.18
140143................................................ 1.0957 18.76
140144................................................ 0.9933 19.79
140145................................................ 1.1514 16.61
140146................................................ 1.0740 23.74
140147................................................ 1.2519 24.82
140148................................................ 1.8274 19.50
140150................................................ 1.6434 27.85
140151................................................ 1.0618 19.30
140152................................................ 1.1951 22.43
140155................................................ 1.3310 17.31
140158................................................ 1.3594 22.27
140160................................................ 1.1737 17.88
140161................................................ 1.2224 19.04
140162................................................ 1.6988 18.42
140164................................................ 1.4390 18.61
140165................................................ 1.0866 15.42
140166................................................ 1.1670 17.54
140167................................................ 1.0995 16.57
140168................................................ 1.1303 16.46
140170................................................ 1.1327 14.14
140171................................................ 0.9915 14.73
140172................................................ 1.5915 20.80
140173................................................ 0.8685 18.48
140174................................................ 1.6130 19.92
140176................................................ 1.2480 21.41
140177................................................ 1.2010 18.17
140179................................................ 1.3630 22.70
140180................................................ 1.4469 23.25
140181................................................ 1.4232 20.55
140182................................................ 1.3607 20.70
140184................................................ 1.2116 14.98
140185................................................ 1.4938 17.36
140186................................................ 1.3429 18.99
140187................................................ 1.5865 17.69
140188................................................ 0.9985 14.84
140189................................................ 1.2534 19.08
140190................................................ 1.0757 15.88
140191................................................ 1.4399 24.74
140193................................................ 1.0289 15.52
140197................................................ 1.2537 17.98
140199................................................ 1.0816 18.83
140200................................................ 1.4773 21.65
140202................................................ 1.3290 22.18
140203................................................ 1.1563 20.78
140205................................................ 0.9296 17.24
140206................................................ 1.2023 20.51
140207................................................ 1.2939 20.20
140208................................................ 1.7156 23.94
140209................................................ 1.6271 17.79
140210................................................ 1.1138 12.66
140211................................................ 1.2095 20.96
140213................................................ 1.2790 26.20
140215................................................ 0.9874 14.45
140217................................................ 1.3233 23.32
140218................................................ 0.9871 15.08
140220................................................ 1.1223 16.73
140223................................................ 1.5508 21.47
140224................................................ 1.4309 22.99
140228................................................ 1.6773 18.67
140230................................................ 0.9381 16.60
140231................................................ 1.5608 21.61
140233................................................ 1.7813 18.37
140234................................................ 1.2225 18.72
140236................................................ 1.0843 13.13
140239................................................ 1.7318 18.88
140240................................................ 1.3948 24.21
140242................................................ 1.6371 22.67
140245................................................ 1.2029 15.56
140246................................................ 1.0621 12.82
140250................................................ 1.3281 23.41
140251................................................ 1.3069 20.58
140252................................................ 1.4989 24.49
140253................................................ 1.1634 16.74
140258................................................ 1.5765 21.13
140271................................................ 0.9795 15.36
140275................................................ 1.2739 17.96
140276................................................ 2.0654 23.72
140280................................................ 1.3786 18.84
140281................................................ 1.6496 23.34
140285................................................ 1.2739 14.71
140286................................................ 1.1863 19.95
140288................................................ 1.6193 21.82
140289................................................ 1.3459 16.45
140290................................................ 1.3383 21.24
140291................................................ 1.3339 22.44
140292................................................ 1.2911 22.71
140294................................................ 1.1347 17.52
140297................................................ ........ 21.47
140300................................................ 1.4559 23.26
150001................................................ 1.1041 21.70
150002................................................ 1.4489 18.76
150003................................................ 1.8053 19.31
150004................................................ 1.5183 19.70
[[Page 41566]]
150005................................................ 1.1499 19.00
150006................................................ 1.2599 20.04
150007................................................ 1.2063 19.53
150008................................................ 1.4364 20.97
150009................................................ 1.3649 18.22
150010................................................ 1.3600 18.48
150011................................................ 1.2166 19.19
150012................................................ 1.6210 20.52
150013................................................ 1.1027 16.00
150014................................................ 1.6030 21.28
150015................................................ 1.2975 22.05
150017................................................ 1.9021 18.89
150018................................................ 1.4575 19.56
150019................................................ 1.0931 15.29
150020................................................ 1.1536 14.46
150021................................................ 1.6905 19.02
150022................................................ 1.0882 17.92
150023................................................ 1.5779 18.66
150024................................................ 1.3427 17.83
150025................................................ 1.4440 18.15
150026................................................ 1.2077 20.51
150027................................................ 1.0057 16.48
150029................................................ 1.3399 21.74
150030................................................ 1.2418 17.33
150031................................................ 1.0791 18.01
150032................................................ ........ 20.64
150033................................................ 1.5759 21.69
150034................................................ 1.4830 21.29
150035................................................ 1.4915 19.82
150036................................................ 1.0011 20.38
150037................................................ 1.2875 17.79
150038................................................ 1.2923 20.25
150039................................................ 1.0012 17.49
150042................................................ 1.2828 17.12
150043................................................ 1.1061 17.98
150044................................................ 1.2617 17.64
150045................................................ 1.0943 17.04
150046................................................ 1.3952 17.32
150047................................................ 1.5995 24.88
150048................................................ 1.1920 16.96
150049................................................ 1.2163 16.85
150050................................................ 1.1659 17.14
150051................................................ 1.5091 18.20
150052................................................ 1.0896 15.36
150053................................................ 0.9867 18.75
150054................................................ 1.1338 17.33
150056................................................ 1.8954 23.30
150057................................................ 2.2387 16.86
150058................................................ 1.7048 20.95
150059................................................ 1.3598 20.80
150060................................................ 1.1844 16.01
150061................................................ 1.2118 17.21
150062................................................ 1.1077 18.41
150063................................................ 1.0850 21.09
150064................................................ 1.1848 17.03
150065................................................ 1.1695 19.01
150066................................................ 1.0217 14.60
150067................................................ 1.1259 17.08
150069................................................ 1.2229 17.39
150070................................................ 0.9568 17.20
150071................................................ 1.0951 14.73
150072................................................ 1.1985 16.11
150073................................................ 1.0647 19.03
150074................................................ 1.6339 18.86
150075................................................ 1.1208 14.98
150076................................................ 1.1839 22.34
150077................................................ 0.8124 17.58
150078................................................ 1.0539 19.01
150079................................................ 1.1723 15.45
150082................................................ 1.5245 17.88
150084................................................ 1.9902 22.92
150086................................................ 1.2532 17.34
150088................................................ 1.3451 19.45
150089................................................ 1.4582 22.94
150090................................................ 1.3308 19.06
150091................................................ 1.0358 19.89
150092................................................ 1.0090 15.92
150094................................................ 0.9814 18.34
150095................................................ 1.0848 17.12
150096................................................ 1.0067 20.03
150097................................................ 1.0940 18.31
150098................................................ 1.1571 14.30
150099................................................ ........ 18.97
150100................................................ 1.6554 17.48
150101................................................ 1.0910 17.56
150102................................................ 1.0778 11.50
150103................................................ 0.9707 17.31
150104................................................ 1.1260 17.26
150105................................................ 1.3381 19.17
150106................................................ 1.0525 18.91
150109................................................ 1.3958 18.23
150110................................................ 0.9834 18.58
150111................................................ 1.1588 16.17
150112................................................ 1.2455 19.82
150113................................................ 1.2372 19.20
150114................................................ 0.9743 16.96
150115................................................ 1.3404 17.06
150122................................................ 1.1625 19.35
150123................................................ 1.1180 15.16
150124................................................ 1.0843 15.07
150125................................................ 1.4619 20.32
150126................................................ 1.4866 20.30
150127................................................ 1.0396 22.81
150128................................................ 1.2478 19.92
150129................................................ 1.1853 23.47
150130................................................ 1.3391 16.41
150132................................................ 1.4200 19.48
150133................................................ 1.1910 16.49
150134................................................ 1.1949 17.06
150136................................................ 0.9556 19.28
160001................................................ 1.2585 19.03
160002................................................ 1.0936 15.37
160003................................................ 0.9994 15.77
160005................................................ 1.0825 15.23
160007................................................ 1.0218 15.66
160008................................................ 1.1402 14.97
160009................................................ 1.2212 16.09
160012................................................ 1.0500 16.54
160013................................................ 1.1368 17.06
160014................................................ 1.0250 15.09
160016................................................ 1.1678 18.37
160018................................................ 0.9630 14.16
160020................................................ 1.0690 14.41
160021................................................ 1.1123 15.49
160023................................................ 1.0852 14.20
160024................................................ 1.6086 18.95
160026................................................ 1.0312 18.66
160027................................................ 1.0851 15.74
160028................................................ 1.2328 20.54
160029................................................ 1.5330 20.40
160030................................................ 1.3897 17.99
160031................................................ 1.1173 15.28
160032................................................ 1.1540 16.18
160033................................................ 1.9249 18.37
160034................................................ 1.1538 14.51
160035................................................ 0.8486 15.92
160036................................................ 1.0544 19.20
160037................................................ 1.0575 18.40
160039................................................ 1.0380 17.63
160040................................................ 1.2725 16.83
160041................................................ 1.0640 15.47
160043................................................ 0.9958 15.63
160044................................................ 1.2165 16.04
160045................................................ 1.8190 20.12
160046................................................ 1.0270 14.77
160047................................................ 1.3715 16.69
160048................................................ 1.2473 13.14
160049................................................ 0.9271 13.36
160050................................................ 1.0702 16.42
160051................................................ 0.8978 14.27
160052................................................ 0.9917 17.55
160054................................................ 1.0301 15.71
160055................................................ 0.9883 14.06
160056................................................ 1.0674 15.38
160057................................................ 1.2430 17.41
160058................................................ 1.8366 20.34
160060................................................ 1.0432 15.95
160061................................................ 1.0830 17.57
160062................................................ 0.9941 14.44
160063................................................ 1.1620 16.30
160064................................................ 1.5338 19.91
160065................................................ 1.0522 16.51
160066................................................ 1.1019 16.26
160067................................................ 1.4239 17.85
160068................................................ 1.0224 15.85
160069................................................ 1.5367 18.49
160070................................................ 0.9958 15.66
160072................................................ 1.0345 14.19
160073................................................ 0.9972 15.05
160074................................................ 1.0388 16.48
160075................................................ 1.0778 17.89
160076................................................ 1.0989 17.31
160077................................................ 1.1087 11.40
160079................................................ 1.4119 17.71
160080................................................ 1.2114 17.81
160081................................................ 1.1520 16.51
160082................................................ 1.9236 18.76
160083................................................ 1.6706 18.41
160085................................................ 0.9972 18.55
160086................................................ 0.9601 16.46
160088................................................ 1.1561 17.53
160089................................................ 1.1911 16.74
160090................................................ 1.0139 16.60
160091................................................ 1.0383 12.19
160092................................................ 1.0120 15.80
160093................................................ 1.0155 15.95
160094................................................ 1.1043 16.56
160095................................................ 1.0299 14.26
160097................................................ 1.0774 15.21
160098................................................ 0.9466 15.54
160099................................................ 0.9654 13.79
160101................................................ 1.0851 17.87
[[Page 41567]]
160102................................................ 1.3432 18.36
160103................................................ 0.9416 17.15
160104................................................ 1.2969 19.74
160106................................................ 1.1113 16.66
160107................................................ 1.1505 16.56
160108................................................ 1.0215 15.42
160109................................................ 1.0167 16.49
160110................................................ 1.5105 18.81
160111................................................ 0.9969 13.17
160112................................................ 1.3695 16.28
160113................................................ 1.0947 14.58
160114................................................ 0.9776 15.58
160115................................................ 0.9770 15.76
160116................................................ 1.1196 16.69
160117................................................ 1.4111 17.29
160118................................................ 0.9954 15.84
160120................................................ 0.9721 12.56
160122................................................ 1.1137 18.52
160124................................................ 1.2998 17.16
160126................................................ 0.9700 17.74
160129................................................ 0.9742 15.89
160130................................................ 1.1286 15.45
160131................................................ 1.0437 14.69
160134................................................ 0.9459 13.32
160135................................................ 1.0163 16.33
160138................................................ 1.0146 15.71
160140................................................ 1.1321 18.80
160142................................................ 1.0188 16.14
160143................................................ 1.1242 15.92
160145................................................ 1.0697 15.17
160146................................................ 1.4411 16.35
160147................................................ 1.2764 18.39
160151................................................ 1.0545 15.74
160152................................................ 0.9425 15.22
160153................................................ 1.7595 19.69
170001................................................ 1.2073 17.44
170004................................................ 1.0739 13.06
170006................................................ 1.1966 19.31
170008................................................ 1.0034 13.90
170009................................................ 1.1479 19.59
170010................................................ 1.3585 17.90
170012................................................ 1.4135 16.79
170013................................................ 1.2818 17.89
170014................................................ 1.0342 17.34
170015................................................ 0.9809 15.89
170016................................................ 1.7098 19.64
170017................................................ 1.1985 17.87
170018................................................ 1.1014 14.28
170019................................................ 1.2400 16.66
170020................................................ 1.4076 16.15
170022................................................ 1.0506 17.94
170023................................................ 1.4694 19.36
170024................................................ 1.0663 13.06
170025................................................ 1.1917 16.37
170026................................................ 1.0821 13.31
170027................................................ 1.3182 16.39
170030................................................ 1.0600 15.24
170031................................................ 0.8926 13.47
170032................................................ 1.0154 14.48
170033................................................ 1.4154 16.05
170034................................................ 1.0335 14.63
170035................................................ 0.8974 15.62
170036................................................ ........ 14.17
170038................................................ 0.9007 14.21
170039................................................ 1.0924 14.30
170040................................................ 1.5839 20.14
170041................................................ 1.0515 11.47
170044................................................ 0.9951 14.78
170045................................................ 1.0889 12.11
170049................................................ 1.3513 18.58
170051................................................ 0.9883 14.16
170052................................................ 1.0435 14.62
170053................................................ 0.9379 9.04
170054................................................ 1.0385 12.77
170055................................................ 0.9812 14.99
170056................................................ 0.8854 14.87
170057................................................ ........ 15.09
170058................................................ 1.1560 18.34
170060................................................ 1.0207 17.23
170061................................................ 1.1617 14.14
170063................................................ 0.8974 11.33
170064................................................ ........ 12.42
170066................................................ 0.9451 14.48
170067................................................ 0.9987 12.78
170068................................................ 1.2647 15.82
170070................................................ 1.0611 12.82
170072................................................ 0.9119 13.34
170073................................................ 1.0417 16.47
170074................................................ 1.2029 14.40
170075................................................ 0.9266 11.26
170076................................................ 1.0180 13.58
170077................................................ 0.9138 12.72
170079................................................ 1.0029 14.29
170080................................................ 0.9644 12.20
170081................................................ 0.9118 12.51
170082................................................ 0.9387 12.39
170084................................................ 0.8978 12.16
170085................................................ 0.8894 14.51
170086................................................ 1.6767 19.85
170088................................................ 0.9319 11.75
170089................................................ 0.9744 18.08
170090................................................ 0.9652 11.27
170092................................................ ........ 12.85
170093................................................ 0.8902 12.78
170094................................................ 0.9571 17.71
170095................................................ 1.0123 15.75
170097................................................ 0.9087 15.85
170098................................................ 1.1360 14.10
170099................................................ 1.1529 13.55
170100................................................ ........ 14.47
170101................................................ 0.9694 12.88
170102................................................ 0.9678 13.24
170103................................................ 1.3272 16.66
170104................................................ 1.4805 19.76
170105................................................ 1.0590 15.93
170106................................................ 0.9336 14.68
170109................................................ 0.9346 16.94
170110................................................ 0.9857 15.55
170112................................................ 1.1452 13.39
170113................................................ 1.0746 13.39
170114................................................ 0.9511 14.51
170115................................................ 0.9977 12.68
170116................................................ 1.0599 15.76
170117................................................ 0.9782 15.28
170119................................................ 0.9657 13.97
170120................................................ 1.2725 16.21
170122................................................ 1.7569 20.13
170123................................................ 1.7222 21.42
170124................................................ 0.9948 10.21
170126................................................ 0.9316 12.13
170128................................................ 0.9613 14.99
170131................................................ ........ 13.10
170133................................................ 1.1278 17.11
170134................................................ 0.8746 14.23
170137................................................ 1.1825 17.42
170139................................................ 1.0034 13.39
170142................................................ 1.3143 17.32
170143................................................ 1.1142 15.88
170144................................................ 1.5081 16.09
170145................................................ 1.1137 16.75
170146................................................ 1.4464 19.97
170147................................................ 1.1950 16.28
170148................................................ 1.3683 17.25
170150................................................ 1.1491 15.43
170151................................................ 0.9386 13.37
170152................................................ 1.0039 13.68
170160................................................ 0.9948 13.31
170164................................................ 0.9849 15.56
170166................................................ 1.1213 17.57
170171................................................ 1.0545 13.81
170175................................................ 1.3044 17.88
170176................................................ 1.6757 20.32
170182................................................ 1.4288 14.20
170183................................................ 1.9802 19.09
170184................................................ ........ 27.01
180001................................................ 1.3845 19.52
180002................................................ 1.0807 18.13
180004................................................ 1.1145 15.99
180005................................................ 1.1967 20.63
180006................................................ 0.9088 11.23
180007................................................ 1.4605 17.20
180009................................................ 1.3630 20.81
180010................................................ 1.9352 17.55
180011................................................ 1.3149 16.93
180012................................................ 1.4399 18.74
180013................................................ 1.4516 17.45
180014................................................ 1.6962 20.80
180016................................................ 1.3326 18.84
180017................................................ 1.3055 15.17
180018................................................ 1.2972 18.90
180019................................................ 1.1916 16.76
180020................................................ 1.1096 17.78
180021................................................ 1.0498 15.16
180023................................................ 0.9502 15.22
180024................................................ 1.4071 15.33
180025................................................ 1.2007 17.17
180026................................................ 1.2061 14.16
180027................................................ 1.2508 14.89
180028................................................ 1.0896 19.35
180029................................................ 1.2291 18.02
180030................................................ 1.1690 17.02
180031................................................ 1.1171 13.79
180032................................................ 1.0592 16.09
180033................................................ 1.0969 13.77
180034................................................ 1.0876 17.32
180035................................................ 1.6449 19.45
180036................................................ 1.1569 19.19
180037................................................ 1.3120 18.81
180038................................................ 1.4617 17.16
180040................................................ 1.9294 19.44
180041................................................ 1.1888 15.17
180042................................................ 1.1678 16.29
[[Page 41568]]
180043................................................ 1.1248 16.61
180044................................................ 1.1967 17.82
180045................................................ 1.3993 17.73
180046................................................ 1.0431 17.91
180047................................................ 1.0016 15.04
180048................................................ 1.2482 19.57
180049................................................ 1.3489 16.08
180050................................................ 1.2187 18.48
180051................................................ 1.3876 15.68
180053................................................ 1.0545 14.63
180054................................................ 1.0894 16.39
180055................................................ 1.2204 14.64
180056................................................ 1.1028 16.62
180058................................................ 1.0446 14.36
180059................................................ 0.8725 14.26
180060................................................ ........ 7.21
180063................................................ 1.0690 11.91
180064................................................ 1.1791 14.49
180065................................................ 1.0777 20.03
180066................................................ 1.0801 18.56
180067................................................ 1.8973 18.53
180069................................................ 1.1243 17.30
180070................................................ 1.1056 13.84
180072................................................ 1.1200 17.85
180075................................................ ........ 15.07
180078................................................ 1.0782 19.16
180079................................................ 1.1816 13.41
180080................................................ 1.0820 15.83
180087................................................ 1.2278 14.97
180088................................................ 1.6070 22.53
180092................................................ 1.2232 16.31
180093................................................ 1.4180 16.83
180094................................................ 1.0265 12.51
180095................................................ 1.1312 13.40
180099................................................ 1.0423 13.70
180101................................................ 1.1766 19.56
180102................................................ 1.4368 17.88
180103................................................ 2.3182 19.22
180104................................................ 1.5485 18.87
180105................................................ 0.8828 14.08
180106................................................ 0.8754 13.61
180108................................................ 0.8268 14.62
180115................................................ 0.9601 17.11
180116................................................ 1.2335 16.94
180117................................................ 1.1154 18.38
180118................................................ 0.9648 12.15
180120................................................ 1.0190 17.81
180121................................................ 1.1698 14.51
180122................................................ 1.0646 16.97
180123................................................ 1.3537 19.00
180124................................................ 1.3291 18.41
180125................................................ 1.1248 19.73
180126................................................ 1.1140 12.40
180127................................................ 1.2901 17.35
180128................................................ 1.0665 17.05
180129................................................ 0.9823 17.86
180130................................................ 1.4358 19.01
180132................................................ 1.2696 17.26
180133................................................ 1.3414 22.23
180134................................................ 1.0880 13.63
180136................................................ 1.8166 17.71
180138................................................ 1.2012 18.61
180139................................................ 1.0562 18.77
180140................................................ 0.9802 20.40
180141................................................ 1.8686 20.01
180142................................................ 1.7788 ......
190001................................................ 0.8863 17.01
190002................................................ 1.6872 18.84
190003................................................ 1.3293 22.15
190004................................................ 1.4227 17.54
190005................................................ 1.5108 16.71
190006................................................ 1.4657 17.73
190007................................................ 1.0554 13.60
190008................................................ 1.6184 16.89
190009................................................ 1.2835 14.21
190010................................................ 1.2068 17.02
190011................................................ 1.1462 15.17
190013................................................ 1.3006 16.57
190014................................................ 1.1871 17.02
190015................................................ 1.2674 18.19
190017................................................ 1.3423 15.79
190018................................................ 1.1075 16.98
190019................................................ 1.7884 17.40
190020................................................ 1.1993 17.31
190025................................................ 1.3078 16.07
190026................................................ 1.5549 17.22
190027................................................ 1.5154 16.19
190029................................................ 1.1492 17.11
190033................................................ 0.9722 10.74
190034................................................ 1.1721 16.51
190036................................................ 1.6846 19.94
190037................................................ 0.9642 12.02
190039................................................ 1.4096 17.17
190040................................................ 1.3336 20.32
190041................................................ 1.6062 17.90
190043................................................ 1.0448 12.57
190044................................................ 1.1671 17.20
190045................................................ 1.4154 21.69
190046................................................ 1.4275 19.35
190048................................................ 1.2068 16.34
190049................................................ 0.9395 16.42
190050................................................ 1.0788 15.38
190053................................................ 1.1493 12.50
190054................................................ 1.2992 16.47
190059................................................ 0.8878 15.84
190060................................................ 1.3886 18.37
190064................................................ 1.5235 19.90
190065................................................ 1.4997 19.39
190071................................................ 0.8370 13.59
190077................................................ 0.8845 12.83
190078................................................ 1.1084 13.50
190079................................................ 1.3543 17.29
190081................................................ 0.8862 12.02
190083................................................ 1.0663 16.14
190086................................................ 1.3280 14.93
190088................................................ 1.2140 19.63
190089................................................ 1.1095 12.79
190090................................................ 1.0412 16.56
190092................................................ ........ 18.07
190095................................................ 0.9939 15.73
190098................................................ 1.5467 19.22
190099................................................ 1.1795 18.92
190102................................................ 1.6260 19.05
190103................................................ 0.9068 15.57
190106................................................ 1.1248 17.75
190109................................................ 1.2488 14.53
190110................................................ 0.9773 12.99
190111................................................ 1.5936 20.04
190112................................................ 1.6944 19.21
190113................................................ 1.3926 18.99
190114................................................ 1.0180 12.91
190115................................................ 1.2776 20.49
190116................................................ 1.1970 12.59
190118................................................ 0.9984 12.95
190120................................................ 0.9918 13.69
190122................................................ 1.2902 14.83
190124................................................ 1.6262 22.38
190125................................................ 1.4998 18.63
190128................................................ 1.1960 19.71
190130................................................ 1.0021 12.43
190131................................................ 1.2634 19.60
190133................................................ 1.0829 13.48
190134................................................ 1.0010 12.68
190135................................................ 1.4336 21.35
190136................................................ 0.9974 11.33
190138................................................ ........ 22.71
190140................................................ 0.9506 12.03
190142................................................ 0.9173 14.98
190144................................................ 1.1852 16.84
190145................................................ 0.9756 13.99
190146................................................ 1.5254 20.09
190147................................................ 0.9772 14.32
190148................................................ 0.9409 14.02
190149................................................ 0.9956 15.19
190151................................................ 1.0763 11.92
190152................................................ 1.5099 20.40
190155................................................ ........ 11.08
190156................................................ 0.9523 12.48
190158................................................ 1.2658 19.62
190160................................................ 1.2656 18.47
190161................................................ 1.0796 14.63
190162................................................ 1.2953 19.50
190164................................................ 1.1850 16.33
190167................................................ 1.1283 16.29
190170................................................ 0.9051 13.58
190173................................................ 1.3386 19.64
190175................................................ 1.4211 20.69
190176................................................ 1.6017 18.82
190177................................................ 1.7127 20.32
190178................................................ 0.9284 10.49
190182................................................ 1.3004 20.03
190183................................................ 1.1900 16.11
190184................................................ 0.9948 14.86
190185................................................ 1.3089 19.37
190186................................................ 0.9392 16.36
190189................................................ ........ 26.54
190190................................................ 0.9164 18.67
190191................................................ 1.1467 18.14
190196................................................ 0.9433 14.87
190197................................................ 1.1821 17.92
190199................................................ 1.1077 13.42
190200................................................ 1.4896 19.41
190201................................................ 1.0997 19.14
190202................................................ 1.1257 17.90
190203................................................ 1.4077 21.31
190204................................................ 1.4949 21.21
190205................................................ 1.9200 18.10
190206................................................ 1.6311 20.06
190207................................................ 1.2616 17.67
190208................................................ 0.8087 14.61
190218................................................ 1.0606 18.16
190223................................................ ........ 19.26
[[Page 41569]]
190227................................................ 1.0049 12.11
190231................................................ 1.5630 16.89
190235................................................ ........ 18.27
190236................................................ 1.4200 22.18
190237................................................ 2.6647 ......
190238................................................ 1.6631 ......
190239................................................ 1.1565 ......
190240................................................ 0.9574 ......
200001................................................ 1.3477 17.49
200002................................................ 1.1150 18.77
200003................................................ 1.0964 16.74
200006................................................ 1.0846 19.80
200007................................................ 1.0259 17.89
200008................................................ 1.2221 20.50
200009................................................ 1.8810 20.64
200012................................................ 1.1802 17.01
200013................................................ 1.1132 16.49
200015................................................ ........ 20.11
200016................................................ 1.0407 17.66
200017................................................ ........ 19.65
200018................................................ 1.2100 17.24
200019................................................ 1.2510 18.64
200020................................................ 1.1517 20.60
200021................................................ 1.1958 19.41
200023................................................ 0.8393 14.92
200024................................................ 1.4795 18.65
200025................................................ 1.2498 19.07
200026................................................ 0.9907 17.28
200027................................................ 1.2361 18.28
200028................................................ 0.9208 16.93
200031................................................ 1.2276 15.90
200032................................................ 1.3282 17.92
200033................................................ 1.7827 21.40
200034................................................ 1.2767 19.24
200037................................................ 1.2288 18.24
200038................................................ 1.1403 19.21
200039................................................ 1.2567 20.29
200040................................................ 1.1161 19.30
200041................................................ 1.1251 17.66
200043................................................ 0.8011 16.54
200050................................................ 1.2048 18.08
200051................................................ 0.9887 19.59
200052................................................ 0.9951 15.12
200055................................................ 1.0880 17.17
200062................................................ 0.9532 16.51
200063................................................ 1.2440 19.67
200066................................................ 1.1429 16.34
210001................................................ 1.4433 18.73
210002................................................ 2.0494 22.84
210003................................................ 1.6842 25.37
210004................................................ 1.3603 23.59
210005................................................ 1.2944 19.62
210006................................................ 1.1143 17.77
210007................................................ 1.8010 21.54
210008................................................ 1.3067 19.50
210009................................................ 1.8608 21.81
210010................................................ 1.1389 14.38
210011................................................ 1.3616 21.24
210012................................................ 1.6214 23.43
210013................................................ 1.3595 18.85
210015................................................ 1.3058 16.69
210016................................................ 1.8547 22.15
210017................................................ 1.2502 17.17
210018................................................ 1.2626 21.41
210019................................................ 1.6155 19.09
210022................................................ 1.4895 21.82
210023................................................ 1.4521 21.80
210024................................................ 1.6929 19.56
210025................................................ 1.3269 19.57
210026................................................ 1.3215 11.64
210027................................................ 1.2849 18.49
210028................................................ 1.1685 18.86
210029................................................ 1.2770 22.39
210030................................................ 1.2555 21.02
210031................................................ 1.3110 15.59
210032................................................ 1.1818 18.50
210033................................................ 1.2403 19.91
210034................................................ 1.3179 16.12
210035................................................ 1.3496 20.61
210037................................................ 1.2643 18.74
210038................................................ 1.4168 23.26
210039................................................ 1.1908 20.73
210040................................................ 1.3185 25.08
210043................................................ 1.2817 18.59
210044................................................ 1.3636 22.24
210045................................................ 1.0866 9.69
210048................................................ 1.2884 22.39
210049................................................ 1.1698 17.67
210051................................................ 1.4028 20.76
210054................................................ 1.3672 23.51
210055................................................ 1.3640 20.10
210056................................................ 1.3926 20.94
210057................................................ 1.3578 22.57
210058................................................ 1.5015 21.50
210059................................................ 1.1916 23.13
210060................................................ 1.2744 ......
210061................................................ 1.1312 20.02
220001................................................ 1.2885 26.32
220002................................................ 1.4675 22.58
220003................................................ 1.1126 19.14
220004................................................ ........ 20.01
220006................................................ 1.3858 22.12
220008................................................ 1.2978 21.89
220010................................................ 1.3476 21.92
220011................................................ 1.0966 28.57
220012................................................ 1.3138 29.51
220015................................................ 1.1694 21.78
220016................................................ 1.3440 23.14
220017................................................ 1.3512 25.26
220019................................................ 1.1553 19.13
220020................................................ 1.2443 19.99
220021................................................ ........ 23.63
220023................................................ 0.6351 18.76
220024................................................ 1.2152 21.59
220025................................................ 1.1428 19.94
220028................................................ 1.4561 22.07
220029................................................ 1.1597 21.87
220030................................................ 1.1060 14.54
220031................................................ 1.9047 28.16
220033................................................ 1.2607 20.41
220035................................................ 1.3065 22.00
220036................................................ 1.6250 24.16
220038................................................ 1.3105 22.35
220041................................................ 1.1892 23.15
220042................................................ 1.2714 25.28
220046................................................ 1.3199 22.47
220049................................................ 1.2818 23.03
220050................................................ 1.1650 20.83
220051................................................ 1.1795 20.48
220052................................................ 1.2991 23.14
220053................................................ 1.1633 21.27
220055................................................ 1.2850 21.57
220057................................................ 1.3594 23.00
220058................................................ 1.1555 20.19
220060................................................ 1.2301 26.17
220062................................................ 0.5637 20.06
220063................................................ 1.2667 20.95
220064................................................ 1.2836 22.18
220065................................................ 1.3716 20.20
220066................................................ 1.3505 20.46
220067................................................ 1.2871 25.74
220068................................................ ........ 6.45
220070................................................ 1.2178 19.77
220071................................................ 1.9238 24.65
220073................................................ 1.3020 25.87
220074................................................ 1.3357 24.05
220075................................................ 1.7963 21.54
220076................................................ 1.2498 24.78
220077................................................ 1.8273 24.80
220079................................................ 1.1002 21.01
220080................................................ 1.3051 20.50
220081................................................ 0.9211 25.34
220082................................................ 1.2653 20.02
220083................................................ 1.1883 23.08
220084................................................ 1.2499 24.66
220086................................................ 1.7929 30.46
220088................................................ 1.6454 23.38
220089................................................ 1.2586 21.79
220090................................................ 1.2248 21.64
220092................................................ 1.1846 17.04
220094................................................ ........ 21.99
220095................................................ 1.1895 21.45
220098................................................ 1.3182 20.86
220100................................................ 1.3672 25.35
220101................................................ 1.4445 24.33
220104................................................ 1.4751 27.53
220105................................................ 1.2705 21.69
220106................................................ 1.2167 24.55
220107................................................ ........ 20.27
220108................................................ 1.1918 22.64
220110................................................ 2.1062 29.19
220111................................................ 1.2452 23.05
220116................................................ 1.9074 24.97
220118................................................ ........ 30.52
220119................................................ 1.2606 22.86
220123................................................ 1.0333 27.31
220126................................................ 1.2501 20.96
220128................................................ ........ 20.56
220133................................................ 0.6976 35.27
220135................................................ 1.2820 25.08
220153................................................ 1.0071 23.90
220154................................................ 0.9026 22.13
220162................................................ 1.5209 ......
220163................................................ 2.0316 27.35
220171................................................ 1.6823 23.43
230001................................................ 1.1547 19.20
230002................................................ 1.2729 21.91
230003................................................ 1.1440 19.61
230004................................................ 1.6897 22.03
230005................................................ 1.2524 19.40
230006................................................ 1.0497 18.47
230007................................................ ........ 19.43
[[Page 41570]]
230012................................................ 0.9628 18.67
230013................................................ 1.3746 20.63
230015................................................ 1.1422 20.43
230017................................................ 1.6115 20.40
230019................................................ 1.5321 21.32
230020................................................ 1.7453 21.32
230021................................................ 1.5006 18.57
230022................................................ 1.2699 19.76
230024................................................ 1.4264 27.96
230027................................................ 1.0344 18.03
230029................................................ 1.5752 21.06
230030................................................ 1.3412 17.70
230031................................................ 1.4268 17.53
230032................................................ 1.7439 20.68
230034................................................ 1.2703 17.23
230035................................................ 1.0782 17.56
230036................................................ 1.2543 21.76
230037................................................ 1.1759 19.07
230038................................................ 1.7538 23.39
230040................................................ 1.1335 20.39
230041................................................ 1.2547 19.03
230042................................................ 1.2347 19.49
230046................................................ 1.9274 25.95
230047................................................ 1.3582 20.64
230053................................................ 1.5879 22.18
230054................................................ 1.8393 19.54
230055................................................ 1.1717 19.84
230056................................................ 0.9022 16.41
230058................................................ 1.1008 18.23
230059................................................ 1.4590 19.51
230060................................................ 1.3289 17.87
230062................................................ 0.9642 16.30
230063................................................ 1.2580 20.22
230065................................................ 1.3189 21.15
230066................................................ 1.3680 21.51
230069................................................ 1.1982 21.79
230070................................................ 1.6482 20.06
230071................................................ 1.1143 22.16
230072................................................ 1.2345 20.43
230075................................................ 1.5088 19.43
230076................................................ 1.4056 23.82
230077................................................ 2.0633 20.39
230078................................................ 1.1156 16.25
230080................................................ 1.2475 18.91
230081................................................ 1.2085 17.95
230082................................................ 1.1156 17.74
230085................................................ 1.2336 17.54
230086................................................ 0.9507 16.98
230087................................................ 1.0836 15.77
230089................................................ 1.2845 21.39
230092................................................ 1.3584 18.96
230093................................................ 1.2332 20.19
230095................................................ 1.1754 16.78
230096................................................ 1.1056 22.56
230097................................................ 1.6198 20.10
230099................................................ 1.1227 20.25
230100................................................ 1.1434 13.11
230101................................................ 1.0673 18.61
230103................................................ 1.0518 19.60
230104................................................ 1.5580 23.47
230105................................................ 1.8005 20.88
230106................................................ 1.1850 18.35
230107................................................ 0.9423 14.67
230108................................................ 1.2110 17.42
230110................................................ 1.3149 17.80
230113................................................ 0.8490 11.17
230115................................................ 1.0569 16.47
230116................................................ 0.8683 16.36
230117................................................ 1.9017 23.94
230118................................................ 1.1392 21.71
230119................................................ 1.3553 23.96
230120................................................ 1.1300 19.64
230121................................................ 1.2281 20.08
230122................................................ 1.3510 18.09
230124................................................ 1.1665 18.89
230125................................................ ........ 15.35
230128................................................ 1.4062 23.58
230130................................................ 1.6919 22.52
230132................................................ 1.3454 26.17
230133................................................ 1.2277 17.57
230134................................................ ........ 15.32
230135................................................ 1.2335 22.74
230137................................................ ........ 18.34
230141................................................ 1.6286 23.05
230142................................................ 1.2833 20.12
230143................................................ 1.2819 16.45
230144................................................ 1.1235 20.99
230145................................................ 1.1243 16.60
230146................................................ 1.2623 18.63
230147................................................ 1.4122 20.51
230149................................................ 1.1319 14.17
230151................................................ 1.4152 20.89
230153................................................ 1.0656 17.33
230154................................................ 0.8898 14.58
230155................................................ 1.0291 16.99
230156................................................ 1.7492 23.61
230157................................................ 1.1708 19.72
230159................................................ 1.0227 18.84
230162................................................ 0.9486 17.77
230165................................................ 1.9365 23.31
230167................................................ 1.7523 20.32
230169................................................ 1.3609 22.86
230171................................................ 1.0638 14.96
230172................................................ 1.1814 20.22
230174................................................ 1.3724 20.85
230175................................................ 2.3801 21.81
230176................................................ 1.2161 21.86
230178................................................ 0.9470 16.08
230180................................................ 1.1228 15.48
230184................................................ 1.2506 17.29
230186................................................ 1.1355 ......
230188................................................ 1.1192 15.56
230189................................................ 0.9459 15.91
230190................................................ 0.8855 23.71
230191................................................ 0.9307 17.12
230193................................................ 1.3034 20.18
230195................................................ 1.3593 22.37
230197................................................ 1.4069 21.62
230199................................................ 1.1010 18.40
230201................................................ 1.2559 15.32
230204................................................ 1.3711 22.95
230205................................................ 0.9890 13.89
230207................................................ 1.2528 20.35
230208................................................ 1.2993 17.15
230211................................................ 0.9109 17.51
230212................................................ 1.0548 22.14
230213................................................ 0.9300 15.32
230216................................................ 1.5720 19.59
230217................................................ 1.2676 20.95
230219................................................ 0.8629 20.70
230221 *.............................................. ........ 21.50
230222................................................ 1.3905 20.84
230223................................................ 1.2683 21.50
230227................................................ 1.4220 21.38
230230................................................ 1.5842 22.53
230232................................................ ........ 12.64
230235................................................ 1.0983 15.95
230236................................................ 1.3279 23.22
230239................................................ 1.1721 19.23
230241................................................ 1.1923 18.85
230244................................................ 1.4096 21.08
230253................................................ 0.9601 21.95
230254................................................ 1.2941 21.28
230257................................................ 0.9124 20.47
230259................................................ 1.1378 21.15
230264................................................ 1.6854 15.18
230269................................................ 1.3102 22.81
230270................................................ 1.2083 20.08
230273................................................ 1.5194 23.40
230275................................................ 0.5244 17.60
230276................................................ 0.5657 18.58
230277................................................ 1.2485 22.50
230278................................................ ........ 16.66
230279................................................ 0.6550 16.04
230280................................................ 1.0995 14.22
230283................................................ 2.2592 ......
240001................................................ 1.5332 22.85
240002................................................ 1.7586 23.02
240004................................................ 1.5987 23.92
240005................................................ 0.8865 16.98
240006................................................ 1.1679 27.11
240007................................................ 1.0673 16.98
240008................................................ 1.1473 21.81
240009................................................ 0.9476 16.69
240010................................................ 1.9899 23.63
240011................................................ 1.1456 18.96
240013................................................ 1.2868 18.97
240014................................................ 1.0965 21.86
240016................................................ 1.3894 19.86
240017................................................ 1.1545 17.23
240018................................................ 1.2702 19.07
240019................................................ 1.1855 20.99
240020................................................ 1.1176 19.57
240021................................................ 0.9884 17.40
240022................................................ 1.1043 19.16
240023................................................ 0.9797 20.39
240025................................................ 1.0961 17.25
240027................................................ 1.0734 16.25
240028................................................ 1.1427 19.38
240029................................................ 1.1507 17.99
240030................................................ 1.2812 18.44
240031................................................ 0.9279 18.07
240036................................................ 1.5882 20.33
240037................................................ 1.0148 18.46
240038................................................ 1.5017 26.35
240040................................................ 1.2710 19.90
240041................................................ 1.1727 19.21
240043................................................ 1.2209 17.31
240044................................................ 1.1345 18.92
240045................................................ 1.1610 20.99
240047 *.............................................. 1.5761 21.86
240048................................................ ........ 23.31
[[Page 41571]]
240049................................................ ........ 22.13
240050................................................ 1.2090 24.50
240051................................................ 0.9678 18.23
240052................................................ 1.3021 19.22
240053................................................ 1.4864 21.20
240056................................................ 1.2521 22.29
240057................................................ 1.8388 23.24
240058................................................ 0.9316 14.91
240059................................................ 1.0446 21.96
240061................................................ 1.7835 25.56
240063................................................ 1.4484 23.54
240064................................................ 1.3231 20.76
240065................................................ 1.1449 12.55
240066................................................ 1.3065 22.05
240069................................................ 1.1937 19.18
240071................................................ 1.1063 19.19
240072................................................ 1.0228 18.00
240073................................................ 0.8981 15.63
240075................................................ 1.2006 21.19
240076................................................ 1.0723 21.07
240077................................................ 0.8989 14.95
240078................................................ 1.5437 22.71
240079................................................ 0.9531 17.82
240080 *.............................................. 1.6136 23.73
240082................................................ 1.1218 18.03
240083................................................ 1.2912 19.29
240084................................................ 1.3307 19.61
240085................................................ 1.0393 18.02
240086................................................ 1.0475 15.33
240087................................................ 1.1670 17.06
240088................................................ 1.4004 21.02
240089................................................ 0.9225 18.42
240090................................................ 1.1253 18.05
240093................................................ 1.2993 18.68
240094................................................ 0.9638 20.57
240096................................................ 0.9927 18.34
240097................................................ 1.1145 23.62
240098................................................ 0.9306 20.60
240099................................................ 1.0713 14.38
240100................................................ 1.2877 19.19
240101................................................ 1.2098 17.75
240102................................................ 0.9288 15.56
240103................................................ 1.2084 16.88
240104................................................ 1.1678 24.02
240105................................................ ........ 14.79
240106................................................ 1.3974 23.78
240107................................................ 0.9782 19.03
240108................................................ 0.9821 16.46
240109................................................ 0.9815 13.15
240110................................................ 0.9379 17.28
240111................................................ 0.9930 17.04
240112................................................ 0.9784 15.32
240114................................................ 0.9362 15.49
240115................................................ 1.6103 22.16
240116................................................ 0.9259 15.18
240117................................................ 1.1442 17.57
240119................................................ 0.8629 22.50
240121................................................ 0.9090 21.37
240122................................................ 1.0827 18.04
240123................................................ 1.0155 15.60
240124................................................ 0.9602 19.05
240125................................................ 0.9736 13.15
240127................................................ 1.0148 14.77
240128................................................ 1.1120 16.08
240129................................................ 0.9953 15.42
240130................................................ 0.9313 15.65
240132................................................ 1.2720 24.50
240133................................................ 1.2168 18.52
240135................................................ 0.9183 13.60
240137................................................ 1.1747 19.18
240138................................................ 0.9423 13.74
240139................................................ 0.9616 17.02
240141................................................ 1.1570 21.99
240142................................................ 1.0110 20.61
240143................................................ 0.9629 14.28
240144................................................ 1.0633 15.87
240145................................................ 0.9100 15.00
240146 *.............................................. 0.9093 16.75
240148................................................ 1.0294 11.34
240150................................................ 0.8795 12.83
240152................................................ 1.0247 20.20
240153................................................ 1.0013 15.61
240154................................................ 1.0226 17.06
240155................................................ 0.9164 20.42
240157................................................ 1.0213 14.69
240160................................................ 1.0612 16.60
240161................................................ 1.0365 15.42
240162................................................ 1.0748 19.04
240163................................................ 0.9730 17.87
240166................................................ 1.1543 16.39
240169................................................ 0.9599 18.62
240170................................................ 1.1064 17.65
240171................................................ 1.0064 16.72
240172................................................ 0.9741 16.07
240173................................................ 0.9970 16.74
240179................................................ 1.0360 16.65
240184................................................ 0.9619 14.40
240187................................................ 1.2498 17.51
240193................................................ 1.0038 16.30
240196................................................ 0.6772 23.27
240200................................................ 0.9005 14.73
240205................................................ 0.9227 ......
240206................................................ 0.8330 ......
240207................................................ 1.2623 23.33
240210................................................ 1.2530 23.84
240211................................................ 0.9634 20.55
250001................................................ 1.6314 18.14
250002................................................ 0.8836 15.60
250003................................................ 0.9911 15.66
250004................................................ 1.5373 17.12
250005................................................ 0.9463 12.00
250006................................................ 0.9631 15.70
250007................................................ 1.2281 19.16
250008................................................ 1.0321 13.32
250009................................................ 1.2665 16.18
250010................................................ 1.0095 13.34
250012................................................ 0.9332 18.48
250015................................................ 1.0380 11.07
250017................................................ 1.0279 17.30
250018................................................ 0.9334 13.47
250019................................................ 1.4828 17.15
250020................................................ 0.9516 14.06
250021................................................ 0.8435 9.08
250023................................................ 0.8955 13.54
250024................................................ 0.8985 11.59
250025................................................ 1.1484 17.89
250027................................................ 0.9764 12.42
250029................................................ 0.8697 14.85
250030................................................ 0.9198 13.63
250031................................................ 1.2472 18.77
250032................................................ 1.2183 17.30
250033................................................ 1.0130 15.76
250034................................................ 1.5442 18.13
250035................................................ 0.8342 17.41
250036................................................ 0.9965 13.79
250037................................................ 0.8826 10.32
250038................................................ 0.9386 13.62
250039................................................ 0.9969 16.51
250040................................................ 1.3140 15.64
250042................................................ 1.2627 16.47
250043................................................ 0.9006 13.65
250044................................................ 0.9882 16.75
250045................................................ 1.2709 19.48
250047................................................ 0.9058 12.10
250048................................................ 1.5287 15.71
250049................................................ 0.8842 10.76
250050................................................ 1.2687 13.92
250051................................................ 0.9276 9.60
250057................................................ 1.1769 14.29
250058................................................ 1.1854 15.42
250059................................................ 1.0826 14.30
250060................................................ 0.7514 7.99
250061................................................ 0.8571 13.97
250063................................................ 0.8309 14.97
250065................................................ 0.8940 12.68
250066................................................ 0.9147 14.33
250067................................................ 1.1605 15.29
250068................................................ 0.8225 11.43
250069................................................ 1.2675 15.77
250071................................................ 0.9001 11.21
250072................................................ 1.4320 16.93
250077................................................ 0.9344 11.41
250078................................................ 1.5476 15.46
250079................................................ 0.8556 19.06
250081................................................ 1.2710 16.14
250082................................................ 1.4184 14.02
250083................................................ 0.9424 9.20
250084................................................ 1.0972 19.74
250085................................................ 0.9906 13.85
250088................................................ 0.9812 16.75
250089................................................ 1.0895 13.05
250093................................................ 1.1743 15.09
250094................................................ 1.3417 17.85
250095................................................ 0.9930 16.36
250096................................................ 1.2105 17.07
250097................................................ 1.2839 18.41
250098................................................ 0.9397 14.30
250099................................................ 1.2925 14.41
250100................................................ 1.2679 16.60
250101................................................ 0.8835 16.31
250102................................................ 1.5198 20.02
250104................................................ 1.4479 17.54
250105................................................ 0.9368 14.60
250107................................................ 0.8802 13.63
250109................................................ 0.8898 14.55
250112................................................ 0.9928 14.20
250117................................................ 1.0623 14.52
250119................................................ 1.0646 12.74
250120................................................ 1.0648 14.41
250122................................................ 1.1767 17.71
250123................................................ 1.2182 17.41
250124................................................ 0.9343 12.67
[[Page 41572]]
250125................................................ 1.2795 14.49
250126................................................ 0.9354 14.71
250127................................................ 0.9230 ......
250128................................................ 1.0364 13.00
250131................................................ 1.0826 10.28
250134................................................ 0.9628 17.98
250136................................................ 0.9183 18.05
250138................................................ 1.2050 17.60
250141................................................ 1.2056 17.12
250145................................................ 0.8696 11.40
250146................................................ 0.9386 13.28
250148................................................ 1.2354 14.82
250149................................................ 0.9692 12.98
250150................................................ 1.2560 ......
260001................................................ 1.6540 17.55
260002................................................ 1.4391 20.59
260003................................................ 1.1323 14.35
260004................................................ 0.9723 13.75
260005................................................ 1.6472 19.71
260006................................................ 1.5189 18.94
260008................................................ 1.0522 16.25
260009................................................ 1.2922 17.94
260011................................................ 1.5359 18.34
260012................................................ 1.0022 14.46
260013................................................ 1.1867 15.54
260015................................................ 1.1785 21.33
260017................................................ 1.1731 15.80
260018................................................ 0.8870 12.23
260019................................................ 1.1516 23.67
260020................................................ 1.8132 21.86
260021................................................ 1.4382 17.57
260022................................................ 1.2554 19.35
260023................................................ 1.4184 15.82
260024................................................ 0.9715 13.47
260025................................................ 1.3027 14.94
260027................................................ 1.6141 21.01
260029................................................ 1.1888 17.47
260030................................................ 1.1362 11.24
260031................................................ 1.5369 18.30
260032................................................ 1.7266 20.81
260034................................................ 1.0233 17.90
260035................................................ 1.0041 12.59
260036................................................ 1.0016 18.31
260039................................................ 1.0672 14.20
260040................................................ 1.6822 15.39
260042................................................ 1.2519 17.44
260044................................................ 1.0069 17.12
260047................................................ 1.6386 17.28
260048................................................ 1.2523 21.43
260050................................................ 1.0553 18.74
260052................................................ 1.3718 17.75
260053................................................ 1.1217 12.01
260054................................................ 1.3547 17.37
260055................................................ 0.9682 13.80
260057................................................ 1.0095 15.33
260059................................................ 1.2434 15.79
260061................................................ 1.1184 15.01
260062................................................ 1.1843 20.26
260063................................................ 1.0723 16.85
260064................................................ 1.3324 16.50
260065................................................ 1.7738 18.47
260066................................................ 1.0120 14.42
260067................................................ 0.8925 12.16
260068................................................ 1.6794 19.83
260070................................................ 1.0404 21.69
260073................................................ 1.0809 13.01
260074................................................ 1.2969 15.45
260077................................................ 1.7295 18.26
260078................................................ 1.1807 15.48
260079................................................ 1.0611 14.83
260080................................................ 0.9884 12.56
260081................................................ 1.6614 18.96
260082................................................ 1.1528 15.79
260085................................................ 1.5832 19.51
260086................................................ 0.9274 14.87
260091................................................ 1.6930 19.61
260094................................................ 1.1892 15.87
260095................................................ 1.3659 19.77
260096................................................ 1.5590 21.72
260097................................................ 1.1452 15.79
260100................................................ 1.0130 15.73
260102................................................ 1.0038 16.37
260103................................................ 1.3185 17.35
260104................................................ 1.7110 19.12
260105................................................ 1.8654 20.80
260107................................................ 1.4527 18.46
260108................................................ 1.8537 19.24
260109................................................ 0.9906 13.44
260110................................................ 1.6721 17.00
260113................................................ 1.2263 14.90
260115................................................ 1.2279 17.90
260116................................................ 1.1041 14.57
260119................................................ 1.2152 16.20
260120................................................ 1.1948 17.13
260122................................................ 1.0917 14.54
260123................................................ 1.0487 14.00
260127................................................ 1.0634 15.95
260128................................................ 1.0338 11.27
260129................................................ ........ 14.64
260131................................................ 1.2601 19.75
260134................................................ 1.1698 16.58
260137................................................ 1.7102 15.22
260138................................................ 1.9094 21.39
260141................................................ 2.0004 17.96
260142................................................ 1.1233 16.03
260143................................................ 1.0016 11.94
260147................................................ 0.9530 13.66
260148................................................ 0.9021 10.34
260158................................................ 1.0574 12.40
260159................................................ 1.0116 18.22
260160................................................ 1.1472 16.19
260162................................................ 1.5667 20.71
260163................................................ 1.2567 14.81
260164................................................ 0.9190 14.31
260166................................................ 1.2194 19.53
260172................................................ 0.9615 12.49
260173................................................ 1.0048 11.98
260175................................................ 1.1265 16.29
260176................................................ 1.7233 19.54
260177................................................ 1.3369 20.75
260178................................................ 1.4649 21.41
260179................................................ 1.6106 20.74
260180................................................ 1.6586 18.54
260183................................................ 1.6585 20.19
260186................................................ 1.5839 18.06
260188................................................ 1.2743 18.58
260189................................................ 0.9387 10.75
260190................................................ 1.1980 18.16
260191................................................ 1.2861 19.34
260193................................................ 1.2221 20.51
260195................................................ 1.2459 15.95
260197................................................ 1.0938 16.46
260198................................................ 1.2956 17.64
260200................................................ 1.2113 18.88
260205................................................ 1.1124 ......
260206................................................ 2.6705 ......
270002................................................ 1.2833 17.19
270003................................................ 1.2141 22.13
270004................................................ 1.6968 21.34
270006................................................ 0.8808 16.19
270007................................................ 1.0011 13.17
270009................................................ 1.0256 17.70
270011................................................ 1.0498 19.82
270012................................................ 1.6001 22.88
270013................................................ ........ 20.40
270014................................................ 1.8500 18.56
270016................................................ 0.9247 19.77
270017................................................ 1.2639 19.58
270019................................................ 1.0268 12.78
270021................................................ 1.1669 16.65
270023................................................ 1.2640 20.36
270026................................................ 0.9053 15.64
270027................................................ 1.0596 9.78
270028................................................ 1.1731 17.21
270029................................................ 0.9212 17.89
270032................................................ 1.1264 17.03
270033................................................ 0.8642 16.46
270035................................................ 1.0021 17.65
270036................................................ 0.9187 14.08
270039................................................ 1.0483 15.35
270040................................................ 1.1242 19.19
270041................................................ 1.0440 16.78
270044................................................ 1.1390 13.46
270046................................................ ........ 17.10
270048................................................ 1.0158 15.84
270049................................................ 1.7683 21.17
270050................................................ 0.9929 18.04
270051................................................ 1.3159 18.95
270052................................................ 1.0056 14.80
270057................................................ 1.3060 20.01
270058................................................ 0.9229 14.07
270059................................................ 0.7506 15.60
270060................................................ 0.9519 14.02
270063................................................ 0.9338 14.23
270073................................................ 1.0809 15.53
270074................................................ 0.8781 ......
270075................................................ 0.8274 ......
270079................................................ 0.9373 15.03
270080................................................ 1.1414 14.04
270081................................................ 0.9580 15.52
270082................................................ 1.1019 16.13
270083................................................ 1.0075 20.82
270084................................................ 0.9157 16.21
280001................................................ 1.0653 17.89
280003................................................ 2.1221 22.00
280005................................................ 1.3612 18.75
280009................................................ 1.7670 18.75
280010................................................ 0.8073 16.54
280011................................................ 0.8552 13.96
280012................................................ ........ 16.41
280013................................................ 1.7273 22.18
280014................................................ 0.9006 15.24
[[Page 41573]]
280015................................................ 1.0732 14.64
280017................................................ 1.0728 14.19
280018................................................ 1.0539 14.85
280020................................................ 1.8150 19.40
280021................................................ 1.1771 16.69
280022................................................ 0.9681 15.71
280023................................................ 1.3944 21.24
280024................................................ 0.9612 13.91
280025................................................ 0.9712 14.27
280026................................................ 1.0404 16.06
280028................................................ 1.0763 15.89
280029................................................ 1.2096 19.05
280030................................................ 1.7625 28.71
280031................................................ 0.9956 13.22
280032................................................ 1.3462 19.39
280033................................................ 1.0807 14.93
280034................................................ ........ 15.28
280035................................................ 0.9131 15.33
280037................................................ 1.0308 16.17
280038................................................ 1.0606 16.47
280039................................................ 1.0660 15.19
280040................................................ 1.7369 18.97
280041................................................ 0.9646 13.39
280042................................................ 1.0402 15.30
280043................................................ 0.9786 15.79
280045................................................ 1.0415 14.27
280046................................................ 1.0475 13.72
280047................................................ 1.1206 18.37
280048................................................ 1.1174 14.07
280049................................................ 1.0856 15.63
280050................................................ 0.8884 15.34
280051................................................ 1.1386 15.85
280052................................................ 1.0615 13.65
280054................................................ 1.2474 17.58
280055................................................ 0.9142 12.99
280056................................................ 0.9322 14.02
280057................................................ 0.9649 15.76
280058................................................ 1.2501 17.88
280060................................................ 1.6246 28.60
280061................................................ 1.4157 17.95
280062................................................ 1.1769 13.67
280064................................................ 1.0166 15.51
280065................................................ 1.2679 18.53
280066................................................ 1.0165 11.64
280068................................................ 0.9402 10.13
280070................................................ 0.9894 13.74
280073................................................ 0.9850 17.06
280074................................................ 0.9716 15.22
280075................................................ 1.1012 13.79
280076................................................ 1.0276 13.92
280077................................................ 1.2963 19.01
280079................................................ 1.0819 9.91
280080................................................ 1.0562 14.35
280081................................................ 1.7212 20.92
280082................................................ 1.0739 13.13
280083................................................ 1.0628 17.55
280084................................................ 0.9626 11.69
280085................................................ 0.8210 21.58
280088................................................ 1.2613 22.11
280089................................................ 0.8817 17.47
280090................................................ 0.8499 14.72
280091................................................ 1.0928 15.22
280092................................................ 0.9078 14.20
280094................................................ 0.9941 15.88
280097................................................ 1.0876 14.30
280098................................................ 0.8785 10.17
280101................................................ 1.0046 17.42
280102................................................ ........ 12.94
280104................................................ 0.9207 13.38
280105................................................ 1.2342 18.78
280106................................................ 1.0160 15.54
280107................................................ 1.1351 13.46
280108................................................ 1.0616 17.22
280109................................................ 0.9496 11.06
280110................................................ 0.9845 12.30
280111................................................ 1.2649 23.08
280114................................................ 0.9211 13.56
280115................................................ 0.9774 16.43
280117................................................ 1.0941 16.82
280118................................................ 0.9071 16.92
280119................................................ 0.9530 ......
280123................................................ ........ 20.77
280125................................................ 1.2264 ......
290001................................................ 1.6989 22.42
290002................................................ 0.9461 20.94
290003................................................ 1.6712 25.01
290005................................................ 1.3324 17.86
290006................................................ 1.2261 19.88
290007................................................ 1.6901 29.69
290008................................................ 1.2555 20.25
290009................................................ 1.6203 22.74
290010................................................ 1.1253 14.48
290011................................................ 1.0959 16.44
290012................................................ 1.3503 21.51
290013................................................ 0.9996 17.09
290014................................................ 1.0332 18.38
290015................................................ 0.9724 17.83
290016................................................ 1.1412 12.79
290019................................................ 1.3301 20.93
290020................................................ 0.9828 26.15
290021................................................ 1.6748 21.13
290022................................................ 1.5940 24.08
290027................................................ 0.8902 16.43
290029................................................ 0.9227 ......
290032................................................ 1.4060 22.79
290036................................................ 0.5760 18.61
290038................................................ 0.9361 23.14
290039................................................ 1.3330 25.80
290041................................................ 1.2649 ......
290043................................................ 1.5247 ......
300001................................................ 1.4811 21.42
300003................................................ 1.9992 23.38
300005................................................ 1.3421 19.99
300006................................................ 1.1762 18.93
300007................................................ 1.0898 19.34
300008................................................ 1.2459 16.46
300009................................................ 1.0636 20.01
300010................................................ 1.2614 19.38
300011................................................ 1.3223 21.24
300012................................................ 1.3247 23.89
300013................................................ 1.1162 18.97
300014................................................ 1.2417 19.80
300015................................................ 1.1328 19.93
300016................................................ 1.2146 18.50
300017................................................ 1.3266 22.34
300018................................................ 1.3652 20.89
300019................................................ 1.2381 20.61
300020................................................ 1.3828 21.97
300021................................................ 1.0721 17.35
300022................................................ 1.1269 17.19
300023................................................ 1.3992 20.39
300024................................................ 1.2667 17.95
300028................................................ 1.2841 18.05
300029................................................ 1.3193 20.90
300033................................................ 1.0937 19.85
300034................................................ 2.1599 23.52
310001................................................ 1.7867 27.60
310002................................................ 1.8508 27.87
310003................................................ 1.2979 27.42
310005................................................ 1.2978 23.05
310006................................................ 1.2138 21.56
310008................................................ 1.3295 24.95
310009................................................ 1.3238 23.19
310010................................................ 1.2493 21.11
310011................................................ 1.2567 23.40
310012................................................ 1.6481 26.32
310013................................................ 1.3716 22.11
310014................................................ 1.6717 28.70
310015................................................ 2.0397 26.76
310016................................................ 1.2889 26.05
310017................................................ 1.3516 26.07
310018................................................ 1.0776 24.53
310019................................................ 1.6759 23.09
310020................................................ 1.3978 19.27
310021................................................ 1.5405 22.65
310022................................................ 1.3233 20.73
310024................................................ 1.3299 22.78
310025................................................ 1.1918 22.81
310026................................................ 1.2343 23.87
310027................................................ 1.3202 21.77
310028................................................ 1.2507 23.52
310029................................................ 1.9457 23.38
310031................................................ 2.7809 25.18
310032................................................ 1.3227 23.30
310034................................................ 1.2856 21.69
310036................................................ 1.1393 19.82
310037................................................ 1.4029 27.44
310038................................................ 2.0126 25.38
310039................................................ 1.2557 22.03
310040................................................ 1.2028 23.99
310041................................................ 1.3458 23.78
310042................................................ 1.2925 24.33
310043................................................ 1.1863 22.09
310044................................................ 1.3355 20.43
310045................................................ 1.4863 28.16
310047................................................ 1.3368 24.52
310048................................................ 1.2892 23.33
310049................................................ 1.2327 24.76
310050................................................ 1.2135 22.59
310051................................................ 1.3946 25.28
310052................................................ 1.3043 22.58
310054................................................ 1.3470 24.74
310057................................................ 1.3024 20.45
310058................................................ 1.1475 26.22
310060................................................ 1.1966 19.11
310061................................................ 1.2040 20.80
310062................................................ ........ 19.27
310063*............................................... 1.3463 21.85
310064................................................ 1.3574 24.21
310067................................................ 1.3006 22.27
310069................................................ 1.2634 24.17
310070................................................ 1.4210 25.04
[[Page 41574]]
310072................................................ 1.3713 22.22
310073................................................ 1.6775 25.63
310074................................................ 1.3809 24.46
310075................................................ 1.4097 26.46
310076................................................ 1.4991 28.90
310077................................................ 1.6678 25.06
310078................................................ 1.4298 23.48
310081................................................ 1.3501 23.89
310083................................................ 1.2768 23.68
310084................................................ 1.3292 24.09
310086................................................ 1.2175 21.44
310087................................................ 1.3344 20.89
310088................................................ 1.2069 22.34
310090................................................ 1.3904 24.24
310091................................................ 1.2672 22.01
310092................................................ 1.3248 22.34
310093................................................ 1.2003 21.23
310096................................................ 1.9959 26.30
310105................................................ 1.2465 24.49
310108................................................ 1.4314 22.88
310110................................................ 1.2678 20.14
310111................................................ 1.2705 21.72
310112................................................ 1.3062 22.52
310113................................................ 1.2906 22.95
310115................................................ 1.3002 20.07
310116................................................ 1.2884 25.24
310118................................................ 1.2517 24.54
310119................................................ 1.7352 29.48
310120................................................ 1.2046 21.69
310121................................................ ........ 18.74
320001................................................ 1.5262 17.85
320002................................................ 1.3456 22.46
320003................................................ 1.0767 15.35
320004................................................ 1.2930 17.24
320005................................................ 1.3126 19.87
320006................................................ 1.3526 18.65
320009................................................ 1.5990 17.64
320011................................................ 1.1443 16.55
320012................................................ 1.0529 16.00
320013................................................ 1.1406 23.84
320014................................................ 1.0812 15.97
320016................................................ 1.1821 18.93
320017................................................ 1.1290 18.15
320018................................................ 1.5139 18.19
320019................................................ 1.5059 19.26
320021................................................ 1.8101 17.16
320022................................................ 1.2310 15.84
320023................................................ 1.0211 16.42
320030................................................ 1.1556 16.53
320031................................................ 0.9386 13.99
320032................................................ 0.8993 18.75
320033................................................ 1.1749 20.31
320035................................................ 1.0245 25.74
320037................................................ 1.1621 17.08
320038................................................ 1.2322 16.29
320046................................................ 1.4424 19.00
320048................................................ 1.4140 19.17
320056................................................ 1.1122 ......
320057................................................ 0.9720 ......
320058................................................ 0.8862 ......
320059................................................ 1.0597 ......
320060................................................ 0.9253 ......
320061................................................ 1.1311 ......
320062................................................ 0.8525 ......
320063................................................ 1.2513 19.83
320065................................................ 1.2154 16.10
320067................................................ 0.8614 57.48
320068................................................ 0.8969 18.18
320069................................................ 0.9807 11.31
320070................................................ 0.9556 ......
320074................................................ 1.0870 18.65
320079................................................ 1.2126 17.07
330001................................................ 1.1862 25.21
330002................................................ 1.4469 26.39
330003................................................ 1.3432 18.05
330004................................................ 1.3046 19.96
330005................................................ 1.6831 24.28
330006................................................ 1.3374 25.92
330007................................................ 1.3674 18.80
330008................................................ 1.1788 18.07
330009................................................ 1.3298 30.42
330010................................................ 1.2856 14.74
330011................................................ 1.3008 18.04
330012................................................ 1.7199 31.51
330013................................................ 2.0374 19.99
330014................................................ 1.3839 27.57
330016................................................ 0.9911 17.41
330019................................................ 1.3601 32.45
330020................................................ 1.0286 14.55
330023................................................ 1.3009 24.27
330024................................................ 1.8309 33.62
330025................................................ 1.1220 16.03
330027................................................ 1.4693 32.50
330028................................................ 1.4098 27.08
330029................................................ 1.1581 16.56
330030................................................ 1.4112 15.06
330033................................................ 1.3199 16.75
330034................................................ 0.5292 30.78
330036................................................ 1.2759 24.32
330037................................................ 1.2233 16.00
330038................................................ 1.1832 16.01
330039................................................ ........ 12.47
330041................................................ 1.2880 30.42
330043................................................ 1.3066 27.63
330044................................................ 1.2646 18.70
330045................................................ 1.3781 27.17
330046................................................ 1.4593 31.98
330047................................................ 1.1968 17.69
330048................................................ 1.2630 17.62
330049................................................ 1.2706 19.31
330053................................................ 1.2225 15.67
330055................................................ 1.5732 30.73
330056................................................ 1.4694 30.22
330057................................................ 1.6858 18.69
330058................................................ 1.3130 16.98
330059................................................ 1.6062 32.23
330061................................................ 1.2760 25.07
330062................................................ 1.0970 15.28
330064................................................ 1.4280 32.87
330065................................................ 1.2350 18.37
330066................................................ 1.2659 19.94
330067................................................ 1.3299 21.29
330072................................................ 1.4098 29.31
330073................................................ 1.1707 15.88
330074................................................ 1.2820 18.16
330075................................................ 1.0916 17.43
330078................................................ 1.4535 17.49
330079................................................ 1.2806 16.76
330080................................................ 1.2173 26.88
330084................................................ 1.0649 23.03
330085................................................ 1.2898 18.78
330086................................................ 1.2276 30.69
330088................................................ 1.0486 25.62
330090................................................ 1.5583 18.68
330091................................................ 1.3777 18.53
330092................................................ 1.0002 12.65
330094................................................ 1.2368 17.72
330095................................................ 1.3283 18.55
330096................................................ 1.1192 16.60
330097................................................ 1.2475 16.96
330100................................................ 0.9953 28.11
330101................................................ 1.7932 31.31
330102................................................ 1.3020 17.52
330103................................................ 1.2013 16.52
330104................................................ 1.4136 28.77
330106................................................ 1.7013 35.87
330107................................................ 1.2670 28.08
330108................................................ 1.2378 17.08
330111................................................ 1.0739 15.20
330114................................................ 0.9034 18.24
330115................................................ 1.1307 16.56
330116................................................ 0.8479 24.23
330118................................................ 1.6335 20.76
330119................................................ 1.7050 34.75
330121................................................ 1.0145 15.85
330122................................................ 1.0108 21.20
330125................................................ 1.8904 19.75
330126................................................ 1.1356 22.70
330127................................................ 1.3751 29.33
330128................................................ 1.3130 27.87
330132................................................ 1.2002 14.70
330133................................................ 1.3616 32.38
330135................................................ 1.1987 18.33
330136................................................ 1.3304 17.60
330140................................................ 1.8211 19.50
330141................................................ 1.3368 25.14
330144................................................ 0.9874 15.51
330148................................................ 1.0682 15.04
330151................................................ 1.0931 13.97
330152................................................ 1.4635 29.48
330153................................................ 1.7143 17.50
330154................................................ 1.7631 ......
330157................................................ 1.3782 20.82
330158................................................ 1.4535 26.05
330159................................................ 1.2598 18.02
330160................................................ 1.4258 30.57
330162................................................ 1.2112 27.72
330163................................................ 1.2668 20.46
330164................................................ 1.3673 19.48
330166................................................ 1.0666 14.18
330167................................................ 1.7231 31.18
330169................................................ 1.4422 33.45
330171................................................ 1.3081 25.43
330175................................................ 1.1866 16.69
330177................................................ 0.9536 14.54
330179................................................ 0.8480 12.69
330180................................................ 1.2149 15.53
330181................................................ 1.3246 32.47
330182................................................ 2.5278 30.93
330183................................................ 1.4710 20.00
330184................................................ 1.3687 27.49
330185................................................ 1.2683 26.95
[[Page 41575]]
330188................................................ 1.2749 18.72
330189................................................ 1.1706 17.66
330191................................................ 1.3142 18.86
330193................................................ 1.3094 29.80
330194................................................ 1.8144 35.57
330195................................................ 1.6168 31.39
330196................................................ 1.2584 28.45
330197................................................ 1.1217 17.00
330198................................................ 1.3910 23.81
330199................................................ 1.3867 27.66
330201................................................ 1.6595 30.33
330202................................................ 1.3321 30.79
330203 *.............................................. 1.3921 19.24
330204................................................ 1.3626 29.37
330205................................................ 1.2157 19.46
330208................................................ 1.2524 25.82
330209................................................ 1.2116 24.88
330211................................................ 1.1008 19.10
330212................................................ 1.1242 21.18
330213................................................ 1.1317 18.51
330214................................................ 1.8270 32.20
330215................................................ 1.2136 17.58
330218................................................ 1.0783 21.71
330219................................................ 1.6448 22.15
330221................................................ 1.2958 32.21
330222................................................ 1.2727 17.81
330223................................................ 1.0436 17.28
330224................................................ 1.2609 21.97
330225................................................ 1.1997 25.80
330226................................................ 1.2800 17.67
330229................................................ 1.3032 16.25
330230................................................ 1.3323 28.86
330231................................................ 1.0181 29.09
330232................................................ 1.2621 19.50
330233................................................ 1.4710 33.30
330234................................................ 2.3453 33.33
330235................................................ 1.1654 19.45
330236................................................ 1.3908 30.70
330238................................................ 1.2201 14.80
330239................................................ 1.2099 17.28
330240................................................ 1.3684 30.48
330241................................................ 2.0212 22.60
330242................................................ 1.2840 24.74
330245................................................ 1.4695 17.28
330246................................................ 1.3231 26.66
330247................................................ 0.8484 27.62
330249................................................ 1.1958 16.48
330250................................................ 1.2389 19.56
330252................................................ ........ 17.04
330254................................................ 1.1711 16.73
330258................................................ 1.2652 30.47
330259................................................ 1.4799 25.25
330261................................................ 1.3017 26.17
330263................................................ 1.0017 19.64
330264................................................ 1.1961 23.14
330265................................................ 1.3299 15.62
330267................................................ 1.3394 23.56
330268................................................ 0.9564 14.62
330270................................................ 2.0232 28.24
330273................................................ 1.2930 25.89
330275................................................ 1.3094 17.42
330276................................................ 1.1580 17.75
330277................................................ 1.1064 17.16
330279................................................ 1.2946 19.91
330285................................................ 1.8724 22.47
330286................................................ 1.3300 25.09
330290................................................ 1.7078 32.58
330293................................................ 1.1263 15.38
330304................................................ 1.2300 29.37
330306................................................ 1.3461 27.62
330307................................................ 1.3055 20.74
330308................................................ ........ 36.84
330314................................................ 1.3296 24.74
330316................................................ 1.2613 28.79
330327................................................ 0.8785 16.97
330331................................................ 1.3605 31.04
330332................................................ 1.2161 27.16
330333................................................ 1.2122 ......
330336................................................ 1.3033 30.17
330338................................................ 1.2486 23.01
330339................................................ 0.9024 19.67
330340................................................ 1.1804 26.92
330350................................................ 1.7352 30.38
330353................................................ 1.2745 33.55
330354................................................ 1.5861 ......
330357................................................ 1.3424 34.75
330359................................................ ........ 29.29
330372................................................ 1.2139 22.50
330381................................................ 1.2974 29.24
330385................................................ 1.1317 28.84
330386................................................ 1.1738 24.67
330387................................................ 0.7617 ......
330389................................................ 1.7654 32.42
330390................................................ 1.3622 29.79
330393................................................ 1.7228 27.99
330394................................................ 1.5602 18.77
330395................................................ 1.3551 37.68
330396................................................ 1.1225 30.72
330397................................................ 1.3731 31.00
330398................................................ 1.3883 30.32
330399................................................ 1.2650 35.52
330400................................................ 0.8755 ......
340001................................................ 1.4550 19.01
340002................................................ 1.8335 18.78
340003................................................ 1.1380 21.97
340004................................................ 1.5053 17.89
340005................................................ 1.1327 14.09
340006................................................ 1.0448 17.81
340007................................................ 1.1625 17.17
340008................................................ 1.1063 18.38
340009................................................ ........ 20.50
340010................................................ 1.3066 17.65
340011................................................ 1.1010 14.92
340012................................................ 1.1766 16.66
340013................................................ 1.2440 17.43
340014................................................ 1.5360 19.92
340015................................................ 1.2395 19.01
340016................................................ 1.1721 16.40
340017................................................ 1.2566 19.22
340018................................................ 1.1435 15.16
340019................................................ 0.9975 13.59
340020................................................ 1.2389 16.75
340021................................................ 1.2577 19.67
340022................................................ 1.1225 16.72
340023................................................ 1.3395 17.21
340024................................................ 1.1417 16.64
340025................................................ 1.2484 16.82
340027................................................ 1.2085 17.30
340028................................................ 1.5314 17.72
340030................................................ 2.0552 20.05
340031................................................ 0.9565 12.39
340032................................................ 1.3524 20.47
340035................................................ 1.0956 18.10
340036................................................ 1.1292 16.97
340037................................................ 1.0029 15.53
340038................................................ 1.1014 17.01
340039................................................ 1.2603 20.15
340040................................................ 1.7863 20.12
340041................................................ 1.2563 17.76
340042................................................ 1.1906 16.63
340044................................................ 1.1019 16.37
340045................................................ 1.0204 12.42
340047................................................ 1.8911 19.60
340048................................................ 0.6134 ......
340049................................................ 0.7590 16.50
340050................................................ 1.1658 18.56
340051................................................ 1.2890 18.60
340052................................................ 0.9879 21.37
340053................................................ 1.6306 19.49
340054................................................ 1.1743 14.47
340055................................................ 1.2601 18.18
340060................................................ 1.0858 17.92
340061................................................ 1.7102 20.85
340063................................................ 1.0122 16.92
340064................................................ 1.1554 17.26
340065................................................ 1.3341 18.32
340067................................................ 1.0091 18.61
340068................................................ 1.2353 16.70
340069................................................ 1.8140 19.99
340070................................................ 1.2558 18.63
340071................................................ 1.1412 16.37
340072................................................ 1.1342 15.60
340073................................................ 1.3877 20.69
340075................................................ 1.2374 18.21
340080................................................ 0.9827 16.85
340084................................................ 1.1280 21.78
340085................................................ 1.1684 16.24
340087................................................ 1.1121 16.70
340088................................................ 1.2483 19.83
340089................................................ 0.9798 13.86
340090................................................ 1.1715 17.85
340091................................................ 1.6767 19.40
340093................................................ 1.0384 15.16
340094................................................ 1.3871 15.96
340096................................................ 1.1735 17.98
340097................................................ 1.1300 21.37
340098................................................ 1.5807 20.17
340099................................................ 1.1289 15.09
340101................................................ 1.0689 15.36
340104................................................ 0.8681 15.87
340105................................................ 1.3487 18.90
340106................................................ 1.1391 18.08
340107................................................ 1.2312 16.95
340109................................................ 1.3520 17.96
340111................................................ 1.1185 14.92
340112................................................ 0.9997 14.60
340113................................................ 1.8588 20.88
340114................................................ 1.6123 20.82
340115................................................ 1.5468 18.67
340116................................................ 1.8562 19.48
340119................................................ 1.2136 16.85
340120................................................ 1.1373 14.38
[[Page 41576]]
340121................................................ 1.0483 15.97
340123................................................ 1.1257 16.22
340124................................................ 1.1103 14.05
340125................................................ 1.4571 19.63
340126................................................ 1.3214 17.72
340127................................................ 1.3040 17.38
340129................................................ 1.2333 19.73
340130................................................ 1.3605 19.44
340131................................................ 1.5410 18.94
340132................................................ 1.2906 16.94
340133................................................ 1.0718 14.35
340137................................................ 1.2697 ......
340138................................................ 1.0653 19.28
340141................................................ 1.7096 22.22
340142................................................ 1.1906 16.09
340143................................................ 1.4510 20.95
340144................................................ 1.2510 19.19
340145................................................ 1.3190 19.20
340146................................................ 1.0415 13.01
340147................................................ 1.2389 19.11
340148................................................ 1.3628 18.42
340151................................................ 1.2111 16.57
340153................................................ 1.8460 20.66
340155................................................ 1.3964 20.42
340156................................................ 0.7271 ......
340158................................................ 1.0716 17.26
340159................................................ 1.1780 16.80
340160................................................ 1.1654 15.53
340162................................................ ........ 16.64
340164................................................ 1.3637 19.68
340166................................................ 1.3042 19.17
340168................................................ 0.4833 14.75
340171................................................ 1.1348 20.05
340173................................................ 1.2020 20.21
350001................................................ 0.9646 11.73
350002................................................ 1.8448 17.28
350003................................................ 1.2042 17.43
350004................................................ 1.9290 17.90
350005................................................ 1.0889 16.03
350006................................................ 1.3866 16.62
350007................................................ 0.9036 13.28
350008................................................ 0.9709 21.70
350009................................................ 1.1851 18.28
350010................................................ 1.1308 15.28
350011................................................ 1.9286 18.49
350012................................................ 1.0793 12.73
350013................................................ 1.0590 16.68
350014................................................ 1.0326 15.79
350015................................................ 1.7240 15.87
350016................................................ ........ 11.63
350017................................................ 1.3378 17.78
350018................................................ 1.0325 13.64
350019................................................ 1.7209 19.40
350021................................................ 0.9859 12.69
350023................................................ 0.9505 12.80
350024................................................ 1.0053 14.37
350025................................................ 0.9820 16.24
350027................................................ 1.0099 17.12
350029................................................ 0.8409 12.80
350030................................................ 1.0653 17.35
350033................................................ 0.9296 14.90
350034................................................ 0.9296 18.32
350035................................................ 0.8734 10.16
350038................................................ 1.0783 18.74
350039................................................ 1.0442 17.31
350041................................................ 0.9447 14.68
350042................................................ 1.0586 16.75
350043................................................ 1.6076 17.16
350044................................................ 0.9014 10.53
350047................................................ 1.1414 17.93
350049................................................ 1.2037 14.53
350050................................................ 0.9242 10.57
350051................................................ 0.9872 17.53
350053................................................ 1.0048 13.94
350055................................................ 0.9884 12.37
350056................................................ 0.9227 14.74
350058................................................ 0.9550 14.35
350060................................................ 0.8626 9.60
350061................................................ 1.0451 14.59
350063................................................ 0.8913 ......
350064................................................ 0.8650 ......
350068................................................ 2.4777 ......
350069................................................ 1.2467 ......
360001................................................ 1.3010 17.39
360002................................................ 1.1805 17.40
360003................................................ 1.7521 22.03
360006................................................ 1.9102 22.09
360007................................................ 1.0878 17.10
360008................................................ 1.2553 17.82
360009................................................ 1.5416 17.53
360010................................................ 1.2807 18.09
360011................................................ 1.2954 18.95
360012................................................ 1.2982 19.22
360013................................................ 1.1484 20.81
360014................................................ 1.1318 19.88
360016................................................ 1.6655 18.77
360017................................................ 1.9312 22.50
360018................................................ 1.6955 21.34
360019................................................ 1.2255 20.17
360020................................................ 1.4599 22.95
360024................................................ 1.3135 18.54
360025................................................ 1.3536 19.29
360026................................................ 1.3128 17.04
360027................................................ 1.4745 20.36
360028................................................ 1.4934 17.27
360029................................................ 1.1928 18.22
360030................................................ 1.3464 15.35
360031................................................ 1.1973 19.90
360032................................................ 1.1566 17.93
360034................................................ 1.3261 15.56
360035 *.............................................. 1.6492 20.33
360036................................................ 1.3101 19.18
360037................................................ 2.1402 22.52
360038................................................ 1.6231 19.89
360039................................................ 1.2936 17.40
360040................................................ 1.2903 18.12
360041................................................ 1.2883 18.42
360042................................................ 1.1662 16.12
360044................................................ 1.1577 16.79
360045................................................ 1.4251 21.18
360046................................................ 1.1457 19.32
360047................................................ 1.1301 15.34
360048................................................ 1.8831 21.17
360049................................................ 1.2259 18.81
360050................................................ 1.2304 12.89
360051................................................ 1.6202 20.95
360052................................................ 1.6991 20.02
360054................................................ 1.2488 16.19
360055................................................ 1.3169 23.27
360056................................................ 1.3944 18.76
360057................................................ 1.0590 13.81
360058................................................ 1.1920 17.92
360059................................................ 1.6176 21.97
360062................................................ 1.4095 20.31
360063................................................ 1.1426 22.79
360064................................................ 1.6125 20.64
360065................................................ 1.2530 19.45
360066................................................ 1.6379 20.03
360067................................................ 1.1487 14.57
360068................................................ 1.7961 21.22
360069................................................ 1.1401 17.83
360070................................................ 1.7813 17.53
360071................................................ 1.4168 23.80
360072................................................ 1.2698 17.97
360074................................................ 1.2995 18.26
360075................................................ 1.3458 18.47
360076................................................ 1.3578 19.59
360077................................................ 1.6203 20.82
360078................................................ 1.2481 20.79
360079................................................ 1.8424 22.00
360080................................................ 1.1428 16.64
360081................................................ 1.3443 19.64
360082................................................ 1.2775 22.86
360083................................................ ........ 18.46
360084................................................ 1.6064 20.09
360085................................................ 1.8845 21.67
360086................................................ 1.4307 17.04
360087................................................ 1.4307 20.04
360088................................................ 1.3186 22.31
360089................................................ 1.1340 20.56
360090................................................ 1.2673 20.40
360091................................................ 1.3221 21.03
360092................................................ 1.1368 15.91
360093................................................ 1.1664 18.57
360094................................................ 1.3406 18.31
360095................................................ 1.2602 18.71
360096................................................ 1.0740 17.16
360098................................................ 1.4616 18.34
360099................................................ 1.0145 18.55
360100................................................ 1.2435 17.66
360101................................................ 1.3302 22.31
360102................................................ 1.2047 19.77
360103................................................ ........ 22.62
360104................................................ 1.1889 ......
360106................................................ 1.2012 16.18
360107................................................ 1.2436 18.62
360108................................................ 1.0496 16.51
360109................................................ 1.0898 19.52
360112................................................ 1.9109 22.57
360113................................................ 1.3312 22.46
360114................................................ 1.0862 16.33
360115................................................ 1.3561 18.19
360116................................................ 1.1098 18.08
360118................................................ 1.3482 18.61
360121................................................ 1.2089 21.10
360123................................................ 1.2389 19.13
360125................................................ 1.1466 18.17
360126................................................ 1.2114 20.46
360127................................................ 1.1478 16.92
360128................................................ 1.1562 15.58
360129................................................ 0.9412 15.52
360130................................................ 1.0130 15.34
[[Page 41577]]
360131................................................ 1.3306 18.29
360132................................................ 1.4151 18.27
360133................................................ 1.6452 19.03
360134................................................ 1.7555 20.24
360136................................................ 1.0165 17.85
360137................................................ 1.7409 20.26
360140................................................ 0.9460 19.13
360141................................................ 1.6436 22.85
360142................................................ 1.0518 17.32
360143................................................ 1.3319 20.44
360144................................................ 1.2938 21.92
360145................................................ 1.6950 19.39
360147................................................ 1.2418 16.59
360148................................................ 1.1492 18.89
360149................................................ 1.2611 18.79
360150................................................ 1.3013 20.63
360151................................................ 1.3912 17.49
360152................................................ 1.5355 22.00
360153................................................ 1.1316 14.89
360154................................................ 1.0439 13.78
360155................................................ 1.3700 20.90
360156................................................ 1.2856 17.92
360159................................................ 1.1775 20.71
360161................................................ 1.3543 19.41
360162................................................ 1.0718 18.61
360163................................................ 1.8529 20.38
360164................................................ ........ 16.16
360165................................................ 1.1711 19.48
360166................................................ ........ 16.98
360170................................................ 1.4463 17.18
360172................................................ 1.3447 18.47
360174................................................ 1.2444 19.09
360175................................................ 1.1884 20.41
360176................................................ 1.1409 15.47
360177................................................ 1.3262 19.41
360178................................................ 1.3137 17.40
360179................................................ 1.4139 19.14
360180................................................ 2.1661 22.09
360184................................................ 0.5560 19.35
360185................................................ 1.2339 18.67
360186................................................ 1.0606 20.86
360187................................................ 1.4030 18.02
360188................................................ 0.9307 17.53
360189................................................ 1.1003 17.37
360192................................................ 1.3355 21.00
360193................................................ ........ 17.69
360194................................................ 1.1609 17.69
360195................................................ 1.1446 19.02
360197................................................ 1.1573 19.42
360200................................................ 0.9129 17.76
360203................................................ 1.1658 15.62
360204................................................ 1.2012 19.35
360210................................................ 1.1911 20.28
360211................................................ 1.2583 19.58
360212................................................ 1.3505 20.23
360213................................................ 1.2574 18.33
360218................................................ 1.3249 18.41
360230................................................ 1.5283 21.44
360231................................................ 1.1689 13.56
360234................................................ 1.3667 22.43
360236................................................ 1.2668 19.49
360239................................................ 1.2640 19.86
360241................................................ 0.4070 22.08
360242................................................ 1.8361 ......
360243................................................ 0.6859 13.58
360244................................................ ........ 10.55
360245................................................ 0.7433 15.06
360247................................................ 0.4015 18.11
360248................................................ ........ 21.65
370001................................................ 1.7346 21.27
370002................................................ 1.2288 14.08
370004................................................ 1.1872 16.77
370005................................................ 0.9385 17.38
370006................................................ 1.1884 12.95
370007................................................ 1.1457 17.15
370008................................................ 1.3742 17.30
370011................................................ 1.0371 14.64
370012................................................ 0.8381 10.80
370013................................................ 1.8493 18.04
370014................................................ 1.1887 19.65
370015................................................ 1.1904 17.82
370016................................................ 1.3340 16.64
370017................................................ 1.1216 12.98
370018................................................ 1.3475 14.24
370019................................................ 1.3147 16.88
370020................................................ 1.2736 13.48
370021................................................ 0.8600 11.26
370022................................................ 1.3152 17.90
370023................................................ 1.2592 16.82
370025................................................ 1.3103 16.40
370026................................................ 1.4917 16.90
370028................................................ 1.8963 19.71
370029................................................ 1.1600 13.89
370030................................................ 1.1994 15.47
370032................................................ 1.6025 16.64
370033................................................ 1.0433 12.39
370034................................................ 1.2299 14.51
370035................................................ 1.7120 18.96
370036................................................ 1.0585 11.46
370037................................................ 1.7309 17.75
370038................................................ 0.9615 12.81
370039................................................ 1.1544 16.27
370040................................................ 1.0110 14.26
370041................................................ 0.9415 17.41
370042................................................ 0.8612 14.61
370043................................................ 0.9299 16.08
370045................................................ 1.0224 12.44
370046................................................ 0.9794 18.15
370047................................................ 1.4234 15.67
370048................................................ 1.2065 17.44
370049................................................ 1.3139 19.84
370051................................................ 0.9449 12.18
370054................................................ 1.3637 16.56
370056................................................ 1.5690 18.88
370057................................................ 1.0262 14.66
370059................................................ 1.1239 16.46
370060................................................ 1.0608 15.12
370063................................................ 1.1026 17.06
370064................................................ 0.9372 8.75
370065................................................ 0.9995 16.56
370071................................................ 1.0270 14.95
370072................................................ 0.8663 14.65
370076................................................ 1.2551 12.86
370077................................................ ........ 17.62
370078................................................ 1.6865 17.24
370079................................................ 0.9319 13.60
370080................................................ 0.9519 14.34
370082................................................ 0.8529 13.54
370083................................................ 0.9651 11.49
370084................................................ 1.0188 21.75
370085................................................ 0.8885 11.88
370086................................................ 1.1192 13.56
370089................................................ 1.2148 14.50
370091................................................ 1.6636 17.58
370092................................................ 0.9955 14.68
370093................................................ 1.7971 18.57
370094................................................ 1.4454 18.38
370095................................................ 0.9872 14.13
370097................................................ 1.3459 23.31
370099................................................ 1.1217 16.26
370100................................................ 0.9773 17.10
370103................................................ 0.9111 15.90
370105................................................ 1.9566 17.68
370106................................................ 1.5308 18.62
370108................................................ 0.9670 12.24
370112................................................ 1.0270 15.25
370113................................................ 1.2331 16.20
370114................................................ 1.6454 15.98
370121................................................ 1.0409 19.55
370122................................................ 1.0456 12.15
370123................................................ 1.4493 16.36
370125................................................ 0.8954 13.55
370126................................................ 0.9646 18.24
370131................................................ 0.9766 16.24
370133................................................ 1.0621 10.02
370138................................................ 1.0502 15.94
370139................................................ 1.0969 13.30
370140................................................ 1.0458 15.23
370141................................................ 1.3710 12.14
370146................................................ 1.0935 12.56
370148................................................ 1.4517 16.41
370149................................................ 1.3477 16.72
370153................................................ 1.1156 15.32
370154................................................ 1.0477 15.91
370156................................................ 1.1036 13.64
370158................................................ 1.0207 15.09
370159................................................ 1.2557 17.83
370163................................................ 0.9854 14.56
370165................................................ 1.2557 13.22
370166................................................ 1.0448 17.82
370169................................................ 1.0466 9.48
370170................................................ 1.0201 ......
370171................................................ 1.0333 ......
370172................................................ 0.8953 ......
370173................................................ 1.0677 ......
370174................................................ 0.7213 ......
370176................................................ 1.2191 16.03
370177................................................ 0.9826 11.88
370178................................................ 0.9826 11.64
370179................................................ 0.9491 19.27
370180................................................ 0.9918 ......
370183................................................ 1.0386 7.62
370186................................................ 0.9783 13.35
370190................................................ 1.4695 13.70
370192................................................ 1.4803 16.74
370196................................................ 0.8822 ......
370197................................................ ........ 21.57
370198................................................ 1.4366 ......
370199................................................ 1.0710 ......
370200................................................ 1.1757 ......
380001................................................ 1.3054 22.03
380002................................................ 1.2171 19.48
[[Page 41578]]
380003................................................ 1.1769 24.74
380004................................................ 1.7367 23.14
380005................................................ 1.1722 23.24
380006................................................ 1.2239 20.54
380007................................................ 1.6506 24.29
380008................................................ 1.0693 21.19
380009................................................ 1.7994 25.17
380010................................................ 1.0403 19.75
380011................................................ 1.1050 21.14
380013................................................ 1.1851 20.10
380014................................................ 1.6519 23.48
380017................................................ 1.9289 23.82
380018................................................ 1.8307 22.08
380019................................................ 1.2451 20.77
380020................................................ 1.4521 21.35
380021................................................ 1.2078 20.64
380022................................................ 1.1103 21.61
380023................................................ 1.1371 19.24
380025................................................ 1.2975 24.67
380026................................................ 1.1401 19.27
380027................................................ 1.2810 20.16
380029................................................ 1.1435 18.57
380031................................................ 0.9408 22.83
380033................................................ 1.7943 23.29
380035................................................ 1.3526 21.65
380036................................................ 1.0855 19.33
380037................................................ 1.2290 21.23
380038................................................ 1.2487 25.58
380039................................................ 1.2583 22.12
380040................................................ 1.2936 21.64
380042................................................ 1.0177 19.81
380047................................................ 1.6722 21.95
380048................................................ 1.0388 18.38
380050................................................ 1.4293 18.25
380051................................................ 1.6373 21.24
380052................................................ 1.2518 17.87
380055................................................ ........ 21.25
380056................................................ 1.1058 17.16
380060................................................ 1.4643 23.29
380061................................................ 1.5204 22.60
380062................................................ 1.2219 18.52
380063................................................ ........ 19.36
380064................................................ 1.3264 19.87
380065................................................ 1.3064 22.17
380066................................................ 1.3262 20.42
380068................................................ ........ 22.76
380069................................................ 1.0690 19.58
380070................................................ 1.3461 24.71
380071................................................ 1.2354 20.47
380072................................................ 0.9961 16.32
380075................................................ 1.4230 22.17
380078................................................ 1.1344 19.10
380081................................................ 1.0229 20.59
380082................................................ 1.2605 22.58
380083................................................ 1.1703 21.81
380084................................................ 1.2427 23.64
380087................................................ 1.2284 14.10
380088................................................ 1.0722 19.52
380089................................................ 1.2782 23.74
380090................................................ 1.2985 27.09
380091................................................ 1.2615 22.83
390001................................................ 1.5197 18.64
390002................................................ 1.3161 18.08
390003................................................ 1.2413 17.24
390004................................................ 1.3985 18.89
390005................................................ 1.0952 16.44
390006................................................ 1.8485 19.60
390007................................................ 1.2517 21.41
390008................................................ 1.1995 16.74
390009................................................ 1.7387 20.12
390010................................................ 1.2493 17.23
390011................................................ 1.2786 18.07
390012................................................ 1.2224 20.02
390013................................................ 1.2401 19.33
390015................................................ 1.1327 12.94
390016................................................ 1.2481 17.07
390017................................................ 1.1841 16.22
390018................................................ 1.2421 19.12
390019................................................ 1.0759 16.40
390022................................................ 1.3526 22.90
390023................................................ 1.2272 19.56
390024................................................ 1.1811 25.03
390025................................................ 0.4279 15.71
390026................................................ 1.2761 22.76
390027................................................ 1.8053 27.69
390028................................................ 1.8916 20.11
390029................................................ 2.0498 19.69
390030................................................ 1.2190 18.40
390031................................................ 1.2148 19.52
390032................................................ 1.2612 18.15
390035................................................ 1.2648 18.51
390036................................................ 1.5398 18.87
390037................................................ 1.3709 22.24
390039................................................ 1.1436 16.54
390040................................................ 0.9484 15.12
390041................................................ 1.2688 19.58
390042................................................ 1.5854 21.13
390043................................................ 1.1832 16.36
390044................................................ 1.6421 19.54
390045................................................ 1.7159 18.46
390046................................................ 1.6104 20.46
390047 *.............................................. 1.7392 24.58
390048................................................ 1.1549 18.38
390049................................................ 1.6110 21.13
390050................................................ 2.1144 20.92
390051................................................ 2.1338 26.05
390052................................................ 1.1515 17.10
390054................................................ 1.2341 17.44
390055................................................ 1.8882 25.90
390056................................................ 1.1205 17.17
390057................................................ 1.3152 19.75
390058................................................ 1.2858 19.25
390060................................................ 1.2088 13.63
390061................................................ 1.4942 20.48
390062................................................ 1.2444 16.45
390063................................................ 1.8378 19.64
390065................................................ 1.2322 20.00
390066................................................ 1.2608 18.71
390067................................................ 1.8018 20.65
390068................................................ 1.3033 17.55
390069................................................ 1.2663 19.28
390070................................................ 1.4159 20.19
390071................................................ 1.1073 16.23
390072................................................ 1.0501 15.56
390073................................................ 1.6671 20.69
390074................................................ 1.2469 16.60
390075................................................ 1.3924 17.27
390076................................................ 1.2799 21.43
390078................................................ 1.1498 18.23
390079................................................ 1.7562 18.20
390080................................................ 1.2916 19.52
390081................................................ 1.2972 23.99
390083................................................ 1.2031 20.59
390084................................................ 1.2677 16.35
390086................................................ 1.1360 17.25
390088................................................ 1.3689 23.49
390090................................................ 1.8001 20.65
390091................................................ 1.1280 18.37
390093................................................ 1.1551 16.63
390095................................................ 1.2033 13.05
390096................................................ 1.4914 19.31
390097................................................ 1.2750 21.41
390100................................................ 1.6552 20.30
390101................................................ 1.2029 17.05
390102................................................ 1.3959 19.49
390103................................................ 1.0911 17.71
390104................................................ 1.0664 15.96
390106................................................ 1.1156 16.28
390107................................................ 1.3308 19.18
390108................................................ 1.4026 21.29
390109................................................ 1.2009 14.66
390110................................................ 1.5954 21.32
390111................................................ 1.9491 28.79
390112................................................ 1.2904 14.04
390113................................................ 1.2508 17.94
390114................................................ 1.2348 22.97
390115................................................ 1.3965 24.72
390116................................................ 1.3025 20.60
390117................................................ 1.1716 16.90
390118................................................ 1.2155 16.90
390119 *.............................................. 1.3896 18.59
390121................................................ 1.3960 18.64
390122................................................ 1.0609 17.46
390123................................................ 1.2758 20.84
390125................................................ 1.2088 15.94
390126................................................ 1.2888 20.94
390127................................................ 1.2287 21.88
390128................................................ 1.2209 19.41
390130................................................ 1.1335 17.33
390131................................................ 1.3299 16.83
390132................................................ 1.2842 20.55
390133................................................ 1.7977 24.61
390135................................................ 1.2393 21.25
390136................................................ 1.1430 17.61
390137................................................ 1.5156 16.56
390138................................................ 1.3213 18.86
390139................................................ 1.5077 22.94
390142................................................ 1.6076 26.80
390145................................................ 1.3889 20.34
390146................................................ 1.2155 17.70
390147................................................ 1.2656 21.11
390150................................................ 1.1805 19.66
390151................................................ 1.2299 20.51
390152................................................ 1.1121 19.15
390153................................................ 1.2219 23.12
390154................................................ 1.2679 15.85
390156................................................ 1.4108 21.16
390157................................................ 1.3940 19.83
390158................................................ ........ 21.60
390160................................................ 1.2390 20.77
390161................................................ 1.1929 12.37
390162................................................ 1.5211 21.02
[[Page 41579]]
390163................................................ 1.2276 15.62
390164................................................ 2.1736 21.59
390166................................................ 1.1138 19.96
390167................................................ ........ 22.91
390168................................................ 1.2592 18.99
390169................................................ 1.3390 18.99
390170................................................ 1.8476 22.99
390173................................................ 1.2211 17.86
390174................................................ 1.6855 25.24
390176................................................ 1.1814 17.36
390178................................................ 1.3114 17.70
390179................................................ 1.3111 21.41
390180................................................ 1.4575 25.12
390181................................................ 1.0728 17.09
390183................................................ 1.1617 19.08
390184................................................ 1.1308 20.75
390185................................................ 1.2169 17.65
390189................................................ 1.1404 18.67
390191................................................ 1.1721 16.20
390192................................................ 1.1726 16.37
390193................................................ 1.1915 16.47
390194................................................ 1.1396 20.15
390195................................................ 1.8300 23.69
390196................................................ 1.5787 ......
390197................................................ 1.2829 18.99
390198................................................ 1.2778 15.45
390199................................................ 1.2683 16.66
390200................................................ 0.9687 13.59
390201................................................ 1.2641 20.50
390203................................................ 1.3610 21.19
390204................................................ 1.2735 20.85
390206................................................ 1.3965 18.57
390209................................................ 1.0811 16.96
390211................................................ 1.2188 17.91
390213................................................ 1.1371 17.44
390215................................................ 1.2554 21.43
390217................................................ 1.2220 19.29
390219................................................ 1.3081 21.63
390220................................................ 1.1645 18.52
390222................................................ 1.3169 20.91
390223................................................ 1.7259 22.65
390224................................................ 0.8838 15.91
390225................................................ 1.1965 18.17
390226................................................ 1.6019 23.16
390228................................................ 1.2988 19.81
390231................................................ 1.5687 24.49
390233................................................ 1.3518 18.77
390235................................................ 1.4228 24.60
390236................................................ 1.2240 17.03
390237................................................ 1.5705 21.75
390238................................................ 1.2725 ......
390242................................................ ........ 18.09
390244................................................ 0.9246 14.41
390245................................................ 1.3207 20.15
390246................................................ 1.1923 17.92
390247................................................ 1.0508 20.67
390249................................................ 0.9293 10.73
390256................................................ 1.8873 23.78
390258................................................ 1.4564 21.36
390260................................................ 1.0990 21.19
390262................................................ 1.9277 18.67
390263................................................ 1.4217 20.09
390265................................................ 1.2937 19.51
390266................................................ 1.2120 16.24
390267................................................ 1.2587 20.51
390268................................................ 1.3361 21.02
390270................................................ 1.3866 17.83
390272................................................ 0.4775 ......
390277................................................ 0.4015 27.10
390278................................................ 0.6656 19.20
390279................................................ 1.0539 13.70
390283................................................ 1.2887 ......
390284................................................ 1.2825 ......
400001................................................ 1.2244 9.86
400002................................................ 1.6964 9.31
400003................................................ 1.3598 9.99
400004................................................ 1.1415 8.48
400005................................................ 1.1222 7.85
400006................................................ 1.1587 10.53
400007................................................ 1.1989 7.86
400009................................................ 1.0514 8.37
400010................................................ 0.8930 11.66
400011................................................ 1.0733 5.68
400012................................................ 1.3553 7.81
400013................................................ 1.2614 8.21
400014................................................ 1.3933 9.54
400015................................................ 1.3572 10.33
400016................................................ 1.3661 12.07
400017................................................ 1.1566 8.57
400018................................................ 1.2826 9.45
400019................................................ 1.6564 10.15
400021................................................ 1.4420 9.91
400022................................................ 1.3356 11.12
400024................................................ 0.9529 7.56
400026................................................ 0.9627 7.12
400027................................................ 1.1026 8.49
400028................................................ 1.2378 8.40
400031................................................ 1.2515 9.78
400032................................................ 1.2192 9.73
400044................................................ 1.2602 11.75
400048................................................ 1.0437 8.92
400061................................................ 1.7071 12.28
400079................................................ 1.2218 7.08
400087................................................ 1.4146 10.40
400094................................................ 0.9953 7.82
400098................................................ 1.3997 7.21
400102................................................ 1.1587 7.73
400103................................................ 1.3967 10.73
400104................................................ 1.2587 9.94
400105................................................ 1.2156 10.17
400106................................................ 1.2572 8.51
400109................................................ 1.4778 10.18
400110................................................ 1.1266 10.53
400111................................................ 1.1973 9.56
400112................................................ 1.0576 12.85
400113................................................ 1.1558 9.48
400114................................................ 1.0813 6.41
400115................................................ 1.0388 9.13
400117................................................ 1.1552 10.04
400118................................................ 1.2390 8.70
400120................................................ 1.2553 9.74
400121................................................ 0.9964 7.11
400122................................................ 1.0235 8.48
400123................................................ 1.2032 9.02
400124................................................ 2.8388 11.48
400125................................................ 1.0258 ......
410001................................................ 1.3403 22.53
410004................................................ 1.2575 22.32
410005................................................ 1.3736 21.24
410006................................................ 1.3072 21.98
410007................................................ 1.6369 20.95
410008................................................ 1.2134 22.61
410009................................................ 1.2947 24.08
410010................................................ 1.1607 27.14
410011................................................ 1.2718 24.37
410012................................................ 1.9093 21.33
410013................................................ 1.2981 25.01
420002................................................ 1.5001 20.20
420004................................................ 1.8174 19.41
420005................................................ 1.1360 15.99
420006................................................ 1.2057 18.24
420007................................................ 1.5723 17.58
420009................................................ 1.1691 17.25
420010................................................ 1.1771 17.91
420011................................................ 1.2447 14.99
420014................................................ 1.0205 16.72
420015................................................ 1.3354 17.18
420016................................................ 0.9537 18.15
420018................................................ 1.8084 19.73
420019................................................ 1.2188 15.55
420020................................................ 1.1847 17.90
420023................................................ 1.4285 20.97
420026................................................ 1.8906 21.90
420027................................................ 1.3311 18.08
420029................................................ ........ 18.35
420030................................................ 1.2089 17.82
420031................................................ 0.8604 13.07
420033................................................ 1.1644 21.09
420036................................................ 1.2900 19.74
420037................................................ 1.1933 21.96
420038................................................ 1.3150 16.15
420039................................................ 1.0732 16.96
420042................................................ ........ 14.66
420043................................................ 1.1871 18.36
420048................................................ 1.2367 18.03
420049................................................ 1.1990 19.23
420051................................................ 1.6460 18.25
420053................................................ 1.1431 16.55
420054................................................ 1.2387 16.55
420055................................................ 1.0582 16.18
420056................................................ 1.1140 15.60
420057................................................ 1.1152 14.50
420059................................................ 0.9721 19.13
420061................................................ 1.1775 16.13
420062................................................ 1.1898 18.95
420064................................................ 1.1047 15.45
420065................................................ 1.3888 19.06
420066................................................ 0.9829 15.50
420067................................................ 1.2167 18.31
420068................................................ 1.3841 17.21
420069................................................ 1.0603 16.32
420070................................................ 1.2337 17.45
420071................................................ 1.3506 18.29
420072................................................ 0.9129 12.60
420073................................................ 1.2811 19.20
420074................................................ 1.0309 13.80
420075................................................ 0.9395 16.29
420078................................................ 1.8574 20.68
420079................................................ 1.5169 18.77
420080................................................ 1.3719 24.83
420081................................................ ........ 20.42
420082................................................ 1.5862 18.88
[[Page 41580]]
420083................................................ 1.3552 23.34
420085................................................ 1.4126 18.55
420086................................................ 1.4345 19.31
420087................................................ 1.5936 18.40
420088................................................ 1.0874 17.91
420089................................................ 1.2957 21.66
420091................................................ 1.2752 18.57
420093................................................ 1.0331 16.77
420094................................................ ........ 32.68
430004................................................ 0.9951 17.84
430005................................................ 1.3596 15.84
430007................................................ 1.0895 14.06
430008................................................ 1.0961 16.76
430010................................................ 1.1568 16.11
430011................................................ 1.2924 16.42
430012................................................ 1.3190 17.78
430013................................................ 1.2075 17.24
430014................................................ 1.3645 18.44
430015................................................ 1.2102 16.41
430016................................................ 1.8688 18.97
430018................................................ 0.8830 14.91
430022................................................ 0.8600 12.95
430023................................................ 0.8726 11.64
430024................................................ 0.9383 13.99
430026................................................ ........ 10.85
430027................................................ 1.7702 18.64
430028................................................ 1.0723 16.72
430029................................................ 0.9695 15.10
430031................................................ 0.9138 12.46
430033................................................ 0.9911 14.64
430034................................................ 0.9542 12.85
430036................................................ 0.9551 13.78
430037................................................ 0.9633 15.95
430038................................................ 1.0095 11.94
430040................................................ 1.0562 13.37
430041................................................ 0.9146 12.62
430043................................................ 1.1343 13.43
430044................................................ 0.9084 16.45
430047................................................ 1.0290 15.62
430048................................................ 1.2374 17.26
430049................................................ 0.8800 14.44
430051................................................ 0.9313 17.21
430054................................................ 0.9661 13.50
430056................................................ 0.8354 11.41
430057................................................ 0.8972 15.15
430060................................................ 1.0902 8.64
430062................................................ ........ 10.89
430064................................................ 1.0315 12.74
430065................................................ ........ 12.77
430066................................................ 0.9635 13.44
430073................................................ 1.0645 14.98
430076................................................ 0.9498 12.25
430077................................................ 1.6674 17.71
430079................................................ 0.9893 12.98
430081................................................ 0.8927 ......
430082................................................ 0.8557 ......
430083................................................ 0.9273 ......
430084................................................ 0.8292 ......
430085................................................ 0.7951 ......
430087................................................ ........ 10.45
430089................................................ 0.8333 17.01
430090................................................ 1.3132 ......
430091................................................ 1.4508 ......
430092................................................ 2.2027 ......
430093................................................ 0.9944 ......
440001................................................ 1.1723 15.31
440002................................................ 1.6655 18.54
440003................................................ 1.2107 17.47
440006................................................ 1.4049 20.66
440007................................................ 1.0023 7.76
440008................................................ 0.9789 15.47
440009................................................ 1.1546 15.46
440010................................................ 0.9316 13.51
440011................................................ 1.3825 17.16
440012................................................ 1.7212 19.06
440014................................................ 1.0054 14.61
440015................................................ 1.8026 21.09
440016................................................ 1.0329 14.94
440017................................................ 1.7407 21.13
440018................................................ 1.2959 18.21
440019................................................ 1.7380 28.22
440020................................................ 1.1314 15.59
440022................................................ ........ 19.02
440023................................................ 1.1026 14.14
440024................................................ 1.2941 18.10
440025................................................ 1.1546 15.28
440026................................................ 0.8073 22.92
440029................................................ 1.2571 18.52
440030................................................ 1.2081 15.57
440031................................................ 1.0313 14.30
440032................................................ 1.0042 13.60
440033................................................ 1.1597 14.04
440034................................................ 1.5624 17.93
440035................................................ 1.2300 18.16
440039................................................ 1.8880 19.37
440040................................................ 0.9695 17.50
440041................................................ 1.0284 13.63
440046................................................ 1.2340 16.88
440047................................................ 0.9232 17.00
440048................................................ 1.8759 18.14
440049................................................ 1.6647 16.71
440050................................................ 1.3886 16.76
440051................................................ 0.9140 14.91
440052................................................ 1.0635 16.27
440053................................................ 1.3256 17.69
440054................................................ 1.1374 12.31
440056................................................ 1.1442 14.25
440057................................................ 1.0332 12.72
440058................................................ 1.2111 18.74
440059................................................ 1.4218 17.53
440060................................................ 1.1643 15.86
440061................................................ 1.1488 16.84
440063................................................ 1.6723 18.29
440064................................................ 1.0849 17.62
440065................................................ 1.2815 18.69
440067................................................ 1.2417 22.07
440068................................................ 1.2254 17.45
440070................................................ 1.0048 15.04
440071................................................ 1.3484 16.27
440072................................................ 1.3554 16.77
440073................................................ 1.2784 18.56
440078................................................ 1.0266 13.09
440081................................................ 1.0930 17.97
440082................................................ 2.0510 23.08
440083................................................ 0.9673 35.10
440084................................................ 1.2069 13.37
440091................................................ 1.6378 19.73
440100................................................ 1.0065 13.95
440102................................................ 1.1291 13.96
440103................................................ 1.1144 19.21
440104................................................ 1.7467 22.39
440105................................................ 1.7762 16.03
440109................................................ 1.0850 14.25
440110................................................ 1.1007 15.92
440111................................................ 1.4511 21.07
440114................................................ 1.0554 13.61
440115................................................ 1.0675 12.97
440120................................................ 1.6383 18.30
440125................................................ 1.5580 16.11
440130................................................ 1.1358 16.67
440131................................................ 1.1191 14.68
440132................................................ 1.1320 15.91
440133................................................ 1.5497 21.51
440135................................................ 1.2187 20.90
440137................................................ 1.0853 14.70
440141................................................ 0.9707 12.48
440142................................................ 1.0003 13.01
440143................................................ 1.0458 17.84
440144................................................ 1.2153 16.67
440145................................................ 0.9558 13.66
440147................................................ 1.7028 22.01
440148................................................ 1.1231 17.64
440149................................................ 1.0963 17.15
440150................................................ 1.3332 13.08
440151................................................ 1.1150 15.43
440152................................................ 2.0217 17.84
440153................................................ 1.1545 16.10
440156................................................ 1.5019 19.61
440157................................................ 1.0816 11.40
440159................................................ 1.1206 17.62
440161................................................ 1.8695 20.76
440162................................................ ........ 14.41
440166................................................ 1.6850 18.14
440168................................................ 1.0595 15.95
440173................................................ 1.6016 18.47
440174................................................ 1.0343 17.01
440175................................................ 1.0711 17.61
440176................................................ 1.3789 18.75
440180................................................ 1.2237 17.34
440181................................................ 0.9669 11.85
440182................................................ 0.9559 20.32
440183................................................ 1.5916 19.44
440184................................................ 1.2535 18.06
440185................................................ 1.1857 18.73
440186................................................ 1.0484 18.53
440187................................................ 1.1034 16.25
440189................................................ 1.4919 16.19
440192................................................ 1.0808 19.97
440193................................................ 1.2258 18.40
440194................................................ 1.2517 20.33
440197................................................ 1.3608 23.11
440200................................................ 1.0409 16.06
440203................................................ 0.9731 16.61
440206................................................ 0.9468 15.55
440209................................................ ........ 14.75
440210................................................ 0.8584 12.33
440211................................................ 0.7028 ......
440212................................................ 1.3679 ......
440213................................................ 2.6309 ......
440214................................................ 1.3295 ......
440215................................................ 3.2594 ......
450002 *.............................................. 1.5331 19.92
[[Page 41581]]
450004................................................ 1.1460 15.28
450005................................................ 1.1874 15.59
450007................................................ 1.2676 15.75
450008................................................ 1.2574 15.75
450010................................................ 1.4353 16.08
450011................................................ 1.5196 18.01
450014................................................ 1.1164 18.22
450015................................................ 1.6333 18.44
450016................................................ 1.6642 17.31
450018................................................ 1.4440 20.41
450020................................................ 0.9574 16.97
450021................................................ 1.8603 22.69
450023................................................ 1.4538 16.64
450024................................................ 1.4522 16.56
450025................................................ 1.7316 16.44
450028................................................ 1.4999 18.43
450029................................................ 1.6790 17.69
450031................................................ 1.4813 20.90
450032................................................ 1.3572 15.24
450033................................................ 1.7147 20.86
450034................................................ 1.5646 18.91
450035................................................ 1.4767 16.81
450037................................................ 1.5593 18.65
450039................................................ 1.4220 22.08
450040................................................ 1.5467 17.52
450042................................................ 1.7755 17.59
450044................................................ 1.6190 21.04
450046................................................ 1.3229 17.09
450047................................................ 1.1484 13.90
450050................................................ 0.9409 13.00
450051................................................ 1.5732 20.08
450052................................................ 1.0005 13.53
450053................................................ 1.1017 17.31
450054................................................ 1.6336 21.98
450055................................................ 1.1134 14.81
450056................................................ 1.6266 20.00
450058................................................ 1.6320 16.98
450059................................................ 1.3025 14.21
450063................................................ 0.9080 13.81
450064................................................ 1.4194 16.42
450065................................................ 1.0265 19.61
450068................................................ 1.9340 22.69
450072................................................ 1.1756 17.38
450073................................................ 1.1201 16.62
450076................................................ 1.7324 ......
450078................................................ 0.8770 13.49
450079................................................ 1.5304 19.49
450080................................................ 1.1737 16.31
450081................................................ 1.0574 16.17
450082................................................ 0.9662 13.30
450083................................................ 1.8059 20.18
450085................................................ 1.0594 14.22
450087................................................ 1.4462 21.48
450090................................................ 1.1225 13.91
450092................................................ 1.2258 15.73
450094................................................ 1.3312 19.42
450096................................................ 1.4157 16.63
450097................................................ 1.3386 18.27
450098................................................ 1.0981 15.48
450099................................................ 1.1520 22.88
450101................................................ 1.4857 16.96
450102................................................ 1.7293 18.85
450104................................................ 1.1823 15.98
450107................................................ 1.5327 20.74
450108................................................ 1.0390 16.15
450109................................................ 0.9217 12.77
450110................................................ ........ 21.44
450111................................................ 1.2307 19.27
450112................................................ 1.2575 14.76
450113................................................ 1.3243 18.53
450118................................................ 1.6605 15.83
450119................................................ 1.4078 18.32
450121................................................ 1.5371 18.23
450123................................................ 1.1890 19.19
450124................................................ 1.6617 21.09
450126................................................ 1.3281 17.45
450128................................................ 1.1958 15.89
450130................................................ 1.5002 17.87
450131................................................ 1.2654 17.62
450132................................................ 1.6202 18.07
450133................................................ 1.6004 19.92
450135................................................ 1.6151 20.81
450137................................................ 1.5720 23.96
450140................................................ 0.9268 18.07
450143................................................ 1.0303 14.46
450144................................................ 1.1036 16.30
450145................................................ 0.8681 14.84
450146................................................ 0.9514 14.20
450147................................................ 1.3107 18.07
450148................................................ 1.2211 22.03
450149................................................ 1.4919 24.00
450150................................................ 0.9050 15.21
450151................................................ 1.1068 14.84
450152................................................ 1.2314 17.38
450153................................................ 1.5422 19.94
450154................................................ 1.1797 13.18
450155................................................ 1.0303 23.77
450157................................................ 1.0679 14.66
450160................................................ 0.9603 8.75
450162................................................ 1.2180 22.20
450163................................................ 1.0045 16.98
450164................................................ 1.1806 20.04
450165................................................ 1.0378 15.16
450166................................................ 0.9271 10.28
450169................................................ ........ 15.88
450170................................................ 0.9642 14.81
450176................................................ 1.2922 16.30
450177................................................ 1.2048 14.73
450178................................................ 1.0236 16.76
450181................................................ 1.0155 14.02
450184................................................ 1.4598 19.97
450185................................................ 1.0280 13.06
450187................................................ 1.1970 17.57
450188................................................ 0.9951 13.78
450191................................................ 1.0175 18.80
450192................................................ 1.1761 19.33
450193................................................ 2.0418 22.73
450194................................................ 1.3020 19.15
450196................................................ 1.4363 16.49
450200................................................ 1.4435 17.38
450201................................................ 1.0156 17.05
450203................................................ 1.1610 18.66
450209................................................ 1.5661 18.66
450210................................................ 1.0520 14.23
450211................................................ 1.3657 17.14
450213................................................ 1.7239 18.45
450214................................................ 1.3278 17.25
450217................................................ 0.9404 11.69
450219................................................ 1.0827 15.42
450221................................................ 1.1951 16.99
450222................................................ 1.4958 18.45
450224................................................ 1.3659 22.83
450229................................................ 1.5753 16.41
450231................................................ 1.6275 17.70
450234................................................ 1.0446 13.30
450235................................................ 1.0697 13.42
450236................................................ 1.1450 15.68
450237................................................ 1.5270 17.40
450239................................................ 1.0085 13.64
450241................................................ 0.9610 14.87
450243................................................ 0.9422 12.36
450246................................................ 1.0263 17.97
450249................................................ 1.0666 11.63
450250................................................ 0.9906 14.91
450253................................................ 1.1245 15.35
450258................................................ 1.0358 13.23
450259................................................ ........ 17.85
450264................................................ 0.8807 13.89
450269................................................ 0.9970 14.93
450270................................................ 1.0799 12.70
450271................................................ 1.2418 15.50
450272................................................ 1.2621 17.95
450276................................................ 1.0970 12.71
450278................................................ 0.8254 13.79
450280................................................ 1.5817 19.49
450283................................................ 1.0456 13.89
450286................................................ ........ 12.12
450288................................................ 1.1566 15.99
450289................................................ 1.4628 18.35
450292................................................ 1.1880 19.51
450293................................................ 0.9416 14.43
450296................................................ 1.3456 20.66
450299................................................ 1.5391 17.97
450303................................................ 0.9610 12.67
450306................................................ 1.0915 13.32
450307................................................ 0.8064 16.68
450309................................................ 1.0981 16.21
450315................................................ 0.9782 20.80
450320................................................ 1.2433 19.63
450321................................................ 0.9220 13.39
450322................................................ 0.5973 12.46
450324................................................ 1.5321 17.87
450327................................................ 0.9680 16.09
450330................................................ 1.1273 18.42
450334................................................ 0.9752 12.27
450337................................................ 0.9914 17.42
450340................................................ 1.4515 15.85
450341................................................ 1.0145 19.18
450346................................................ 1.4978 17.10
450347................................................ 1.2191 17.69
450348................................................ 1.1295 12.94
450351................................................ 1.2160 15.98
450352................................................ 1.1896 17.85
450353................................................ 1.1368 15.00
450355................................................ 1.0439 14.32
450358................................................ 2.0749 21.28
450362................................................ 1.0930 15.35
450369................................................ 1.0526 15.19
450370................................................ 1.2091 15.44
450371................................................ 1.2416 11.90
450372................................................ 1.2361 19.86
450373................................................ 1.1050 17.60
[[Page 41582]]
450374................................................ 0.8698 12.83
450378................................................ 1.2110 23.16
450379................................................ 1.5565 20.28
450381................................................ 0.9516 15.62
450388................................................ 1.7788 17.56
450389................................................ 1.2896 18.15
450393................................................ 1.2509 18.74
450395................................................ 1.0405 16.67
450399................................................ 0.9427 16.31
450400................................................ 1.3730 14.08
450403................................................ 1.2446 21.37
450411................................................ 0.9314 14.05
450417................................................ 1.0243 13.85
450418................................................ 1.3882 20.58
450419................................................ 1.2157 21.82
450422................................................ 1.0412 24.53
450423................................................ 1.5370 19.44
450424................................................ 1.2472 17.57
450429................................................ 1.1166 11.38
450431................................................ 1.5621 16.27
450438................................................ 1.1335 16.55
450446................................................ 0.7614 21.97
450447................................................ 1.3915 16.61
450451................................................ 1.1857 19.64
450457................................................ 1.8458 19.77
450460................................................ 1.0022 14.22
450462................................................ 1.7379 20.13
450464................................................ 0.9349 13.47
450465................................................ 1.3025 15.22
450467................................................ 1.0721 15.60
450469................................................ 1.3893 22.10
450473................................................ 1.0194 14.19
450475................................................ 1.0898 16.25
450484................................................ 1.4878 19.59
450488................................................ 1.3277 18.68
450489................................................ 0.9699 14.57
450497................................................ 1.1185 11.92
450498................................................ 0.9726 12.02
450508................................................ 1.3869 19.87
450514................................................ 1.0763 22.28
450517................................................ 0.9630 12.87
450518................................................ 1.5221 19.01
450523................................................ 1.4824 20.26
450530................................................ 1.1935 22.91
450534................................................ 0.9667 24.08
450535................................................ 1.2294 21.26
450537................................................ 1.3395 21.74
450538................................................ ........ 19.69
450539................................................ 1.2636 14.25
450544................................................ 1.1451 19.38
450545................................................ 1.3921 16.97
450547................................................ 1.0630 13.81
450551................................................ 1.1015 13.91
450558................................................ 1.7932 20.02
450559................................................ ........ 13.46
450561................................................ ........ 16.82
450563................................................ 1.2612 30.37
450565................................................ 1.2556 16.45
450570................................................ 1.1337 17.71
450571................................................ 1.4934 16.97
450573................................................ 0.9884 15.67
450574................................................ 0.9302 14.24
450575................................................ 1.1417 19.06
450578................................................ 0.9369 16.87
450580................................................ 1.1529 15.36
450583................................................ 1.0313 15.50
450584................................................ 1.1775 13.37
450586................................................ 1.0568 12.84
450587................................................ 1.1748 17.11
450591................................................ 1.1439 17.92
450596................................................ 1.2187 14.82
450597................................................ 0.9686 16.18
450603................................................ 0.7880 12.77
450604................................................ 1.3018 15.48
450605................................................ 1.1881 20.15
450609................................................ 0.8938 10.73
450610................................................ 1.4658 16.75
450614................................................ 0.9889 13.83
450615................................................ 1.0752 14.75
450617................................................ 1.3304 19.54
450620................................................ 1.1230 13.71
450623................................................ 1.1370 21.83
450626................................................ 1.0095 19.79
450628................................................ 1.0152 16.83
450630................................................ 1.5196 19.19
450631................................................ 1.6627 17.56
450632................................................ 0.9391 12.73
450633................................................ 1.5491 20.72
450634................................................ 1.6032 20.29
450638................................................ 1.5279 19.70
450639................................................ 1.4801 20.31
450641................................................ 1.0503 13.50
450643................................................ 1.2187 17.43
450644................................................ 1.4341 20.79
450646................................................ 1.4580 19.99
450647................................................ 1.8895 22.42
450648................................................ 1.0047 14.75
450649................................................ 1.0310 15.82
450651................................................ 1.6794 20.73
450652................................................ 0.9055 16.65
450653................................................ 1.0887 19.28
450654................................................ 0.9509 13.88
450656................................................ 1.3892 18.73
450658................................................ 0.9617 15.15
450659................................................ 1.4870 20.56
450661................................................ 1.1054 20.22
450662................................................ 1.4695 18.68
450665................................................ 0.8670 15.44
450666................................................ 1.3171 19.35
450668................................................ 1.6278 18.72
450669................................................ 1.3458 22.28
450670................................................ 1.3452 18.20
450672................................................ 1.5856 21.21
450673................................................ 1.0157 13.84
450674................................................ 1.1487 20.62
450675................................................ 1.3667 23.26
450677................................................ 1.3315 18.79
450678................................................ 1.4770 20.75
450681................................................ 1.3177 ......
450683................................................ 1.2748 21.17
450684................................................ 1.2383 22.85
450686................................................ 1.5942 15.01
450688................................................ 1.3164 20.90
450690................................................ 1.3880 22.41
450694................................................ 1.1399 18.49
450696................................................ 1.3358 17.57
450697................................................ 1.3675 15.93
450698................................................ 0.9133 14.40
450700................................................ 0.9460 15.12
450702................................................ 1.5056 21.01
450703................................................ 1.1321 18.80
450704................................................ 1.2429 21.62
450705................................................ 0.8800 22.32
450706................................................ 1.1954 21.38
450709................................................ 1.1866 19.77
450711................................................ 1.6330 18.24
450712................................................ 0.5453 16.89
450713................................................ 1.4858 23.60
450715................................................ 1.4308 19.77
450716................................................ 1.2691 19.99
450717................................................ 1.2889 19.45
450718................................................ 1.2002 19.07
450723................................................ 1.4188 19.70
450724................................................ 1.2574 20.07
450725................................................ ........ 19.56
450727................................................ 1.0500 17.75
450728................................................ 0.8255 12.93
450730................................................ 1.3987 20.91
450733................................................ 1.4696 20.37
450735................................................ 0.8297 8.00
450742................................................ 1.2714 20.78
450743................................................ 1.4590 15.95
450746................................................ 0.9207 20.75
450747................................................ 1.3342 17.38
450749................................................ 1.0361 12.95
450750................................................ 1.0162 14.72
450751................................................ 1.2134 22.25
450754................................................ 0.9408 14.89
450755................................................ 1.1073 14.71
450757................................................ 0.8766 13.96
450758................................................ 1.9447 18.65
450760................................................ 1.2078 18.07
450761................................................ 0.9462 11.14
450763................................................ 1.0029 17.56
450766................................................ 2.0818 21.81
450769................................................ 0.8516 13.62
450770................................................ 0.9940 16.83
450771................................................ 1.9082 21.58
450774................................................ 1.6697 16.52
450775................................................ 1.3660 19.97
450776................................................ 1.0045 10.20
450777................................................ 0.9770 19.59
450779................................................ 1.2931 22.97
450780................................................ 1.7380 15.28
450785................................................ 0.9897 18.55
450788................................................ 1.5021 20.98
450794................................................ ........ 18.40
450795................................................ 0.9879 14.17
450796................................................ 3.3883 17.45
450797................................................ 0.7701 18.59
450798................................................ 0.7662 9.22
450801................................................ 1.4581 16.61
450802................................................ 1.4444 18.90
450803................................................ 1.0992 16.20
450804................................................ 1.7531 20.22
450807................................................ 0.8919 13.23
450808................................................ 1.9250 45.47
450809................................................ 1.5460 19.03
450810................................................ 0.9739 ......
450811................................................ 2.3971 18.38
450812................................................ ........ 20.74
450813................................................ 0.9718 ......
[[Page 41583]]
450815................................................ 2.5623 ......
450817................................................ 0.6826 ......
450818................................................ 1.2025 ......
450819................................................ 1.5000 ......
450820................................................ 1.0411 ......
450822................................................ 1.2110 ......
460001................................................ 1.7793 20.63
460003................................................ 1.6046 20.60
460004................................................ 1.7755 20.82
460005................................................ 1.6581 17.58
460006................................................ 1.3373 19.65
460007................................................ 1.3076 20.57
460008................................................ 1.3677 21.03
460009................................................ 1.8478 21.11
460010................................................ 2.0972 21.25
460011................................................ 1.3205 16.71
460013................................................ 1.4303 20.33
460014................................................ 1.2254 19.55
460015................................................ 1.2396 20.10
460016................................................ 0.9953 18.08
460017................................................ 1.3888 26.03
460018................................................ 0.9230 16.86
460019................................................ 1.0510 17.37
460020................................................ 0.9556 17.03
460021................................................ 1.3848 20.26
460022................................................ 0.9569 18.21
460023................................................ 1.1785 21.33
460024................................................ ........ 13.03
460025................................................ 0.8243 12.51
460026................................................ 1.0605 17.34
460027................................................ 0.9545 20.83
460029................................................ 1.0958 17.25
460030................................................ 1.1918 17.22
460032................................................ 0.9792 19.55
460033................................................ 0.9753 15.72
460035................................................ 0.9477 14.28
460036................................................ 1.0005 22.38
460037................................................ 0.9080 18.77
460039................................................ 1.0603 24.48
460041................................................ 1.3072 21.69
460042................................................ 1.3714 17.85
460043................................................ 0.9896 23.90
460044................................................ 1.1363 20.69
460046................................................ ........ 17.11
460047................................................ 1.6723 21.38
460049................................................ 1.9825 18.82
460050................................................ ........ 26.25
460051................................................ 1.1552 20.98
460052................................................ 1.4619 ......
470001................................................ 1.3011 19.61
470003................................................ 1.8338 22.59
470004................................................ 1.0674 18.10
470005................................................ 1.2285 21.51
470006................................................ 1.2408 18.39
470008................................................ 1.2590 19.41
470010................................................ 1.0678 19.47
470011................................................ 1.1504 21.20
470012................................................ 1.2780 18.52
470015................................................ 1.1985 19.26
470018................................................ 1.2252 20.42
470020................................................ 0.9900 18.99
470023................................................ 1.3197 20.64
470024................................................ 1.1528 20.41
490001................................................ 1.1931 24.76
490002................................................ 1.0751 12.99
490003................................................ 0.6419 18.00
490004................................................ 1.2740 18.77
490005................................................ 1.5963 16.91
490006................................................ 1.2147 15.23
490007................................................ 2.0919 18.43
490009................................................ 1.9489 22.95
490010................................................ 1.0335 18.58
490011................................................ 1.4655 18.75
490012................................................ 1.1933 13.78
490013................................................ 1.2476 16.93
490014................................................ 1.5333 24.56
490015................................................ 1.5161 19.36
490017................................................ 1.3895 17.32
490018................................................ 1.3002 17.94
490019................................................ 1.1951 17.53
490020................................................ 1.2248 17.67
490021................................................ 1.3810 19.45
490022................................................ 1.5532 20.72
490023................................................ 1.2186 18.96
490024................................................ 1.6762 16.89
490027................................................ 1.1131 14.42
490030................................................ 1.1907 10.50
490031................................................ 1.0734 15.82
490032................................................ 1.7204 21.56
490033................................................ 1.1999 18.33
490037................................................ 1.1999 15.97
490038................................................ 1.2143 15.71
490040................................................ 1.4733 22.52
490041................................................ 1.2747 16.55
490042................................................ 1.2324 15.27
490043................................................ 1.3532 20.68
490044................................................ 1.3213 17.63
490045................................................ 1.2161 19.63
490046................................................ 1.5370 18.61
490047................................................ 1.1078 17.16
490048................................................ 1.5688 17.89
490050................................................ 1.4272 22.71
490052................................................ 1.6372 16.94
490053................................................ 1.3233 15.69
490054................................................ 1.0319 15.55
490057................................................ 1.5739 19.07
490059................................................ 1.5941 20.37
490060................................................ 1.0645 19.20
490063................................................ 1.7721 28.25
490066................................................ 1.3274 16.50
490067................................................ 1.2535 17.19
490069................................................ 1.4182 15.70
490071................................................ 1.4083 19.47
490073................................................ 1.5076 26.14
490074................................................ ........ 19.34
490075................................................ 1.3785 19.19
490077................................................ 1.2263 19.79
490079................................................ 1.3128 16.44
490083................................................ ........ 16.64
490084................................................ 1.1308 16.38
490085................................................ 1.1582 16.40
490088................................................ 1.1286 15.60
490089................................................ 1.0694 15.86
490090................................................ 1.1220 16.28
490091................................................ 1.2330 19.99
490092................................................ 1.2219 15.69
490093................................................ 1.4339 16.48
490094................................................ 1.0922 16.79
490095................................................ ........ 18.25
490097................................................ 1.2096 15.86
490098................................................ 1.2068 14.70
490099................................................ 0.9555 16.87
490100................................................ ........ 17.22
490101................................................ 1.2286 25.09
490104................................................ 0.7018 28.49
490105................................................ 0.5822 18.25
490106................................................ 0.8713 16.91
490107................................................ 1.3326 22.41
490108................................................ 0.8935 19.75
490109................................................ 0.8779 21.16
490110................................................ 1.2994 15.84
490111................................................ 1.2000 17.35
490112................................................ 1.6550 20.52
490113................................................ 1.3249 23.08
490114................................................ 1.1582 16.91
490115................................................ 1.1600 17.10
490116................................................ 1.1704 16.44
490117................................................ 1.1543 13.84
490118................................................ 1.7091 20.87
490119................................................ 1.3367 17.87
490120................................................ 1.3095 19.98
490122................................................ 1.3605 23.97
490123................................................ 1.1355 16.85
490124................................................ 1.0893 19.36
490126................................................ 1.3233 18.23
490127................................................ 1.0410 14.48
490129................................................ 1.0746 27.47
490130................................................ 1.3119 16.28
490132................................................ 1.0183 17.02
500001................................................ 1.4869 21.35
500002................................................ 1.4055 21.04
500003................................................ 1.4016 24.31
500005................................................ 1.7533 23.48
500007................................................ 1.3352 22.43
500008................................................ 1.9490 24.19
500011................................................ 1.3373 25.18
500012................................................ 1.5530 22.28
500014................................................ 1.5641 23.93
500015................................................ 1.3293 23.24
500016................................................ 1.4955 23.90
500019................................................ 1.3833 22.37
500021................................................ 1.4802 24.46
500023................................................ 1.2073 27.19
500024................................................ 1.6886 24.05
500025................................................ 1.9090 23.96
500026................................................ 1.4529 23.35
500027................................................ 1.6832 25.05
500028................................................ 1.0717 18.86
500029................................................ 0.9086 16.81
500030................................................ 1.4513 24.13
500031................................................ 1.2483 23.37
500033................................................ 1.3309 21.39
500036................................................ 1.3911 21.90
500037................................................ 1.1389 19.68
500039................................................ 1.3828 23.32
500041................................................ 1.3244 24.85
500042................................................ 1.4121 22.13
500043................................................ 1.0107 20.25
500044................................................ 1.9371 23.11
500045................................................ 1.0116 22.10
500048................................................ 0.9601 19.30
500049................................................ 1.4695 22.95
[[Page 41584]]
500050................................................ 1.3489 20.94
500051................................................ 1.6736 24.48
500052................................................ 1.1621 ......
500053................................................ 1.3284 22.05
500054................................................ 1.8781 22.90
500055................................................ 1.1284 22.88
500057................................................ 1.3026 18.04
500058................................................ 1.4834 23.40
500059................................................ 1.0767 22.54
500060................................................ 1.3712 23.54
500061................................................ 1.0000 20.40
500062................................................ 1.0655 19.46
500064................................................ 1.6382 24.53
500065................................................ 1.2532 21.42
500068................................................ 1.0543 18.70
500069................................................ 1.1155 20.63
500071................................................ 1.2837 19.38
500072................................................ 1.2021 24.46
500073................................................ 0.9531 21.43
500074................................................ 1.1055 18.65
500077................................................ 1.3298 23.21
500079................................................ 1.3220 22.98
500080................................................ 0.8180 13.80
500084................................................ 1.2784 22.22
500085................................................ 0.9302 28.61
500086................................................ 1.2601 22.31
500088................................................ 1.2967 23.70
500089................................................ 1.0515 17.94
500090................................................ 0.8380 16.33
500092................................................ 1.0165 17.29
500094................................................ 0.8803 18.11
500096................................................ 0.9394 20.96
500097................................................ 1.0798 20.80
500098................................................ 1.0464 12.99
500101................................................ 1.0108 19.45
500102................................................ 0.9022 20.33
500104................................................ 1.2616 22.58
500106................................................ 0.9351 18.71
500107................................................ 1.2053 17.30
500108................................................ 1.7383 27.21
500110................................................ 1.2107 21.41
500118................................................ 1.1490 22.92
500119................................................ 1.3555 21.57
500122................................................ 1.2755 21.91
500123................................................ 0.9495 19.58
500124................................................ 1.3681 24.15
500125................................................ 1.0521 16.63
500129................................................ 1.6409 23.60
500132................................................ 0.9686 19.36
500134................................................ 0.6491 20.96
500138................................................ 3.6799 ......
500139................................................ 1.4682 20.88
500141................................................ 1.3726 22.94
500143................................................ 0.5954 17.60
500146................................................ ........ 17.85
510001................................................ 1.9499 17.83
510002................................................ 1.2866 17.34
510005................................................ 1.0198 14.43
510006................................................ 1.2719 17.88
510007................................................ 1.5729 20.25
510008................................................ 1.2172 17.37
510012................................................ 1.0087 16.50
510013................................................ 1.1012 16.62
510015................................................ 0.9677 14.79
510016................................................ ........ 12.03
510018................................................ 1.0741 16.48
510020................................................ 1.0848 12.65
510022................................................ 1.8970 19.84
510023................................................ 1.2380 15.94
510024................................................ 1.5836 18.80
510026................................................ 1.0574 13.46
510027................................................ 0.9600 17.58
510028................................................ 1.0520 20.73
510029................................................ 1.2855 17.05
510030................................................ 1.0520 18.31
510031................................................ 1.4131 18.49
510033................................................ 1.2904 18.81
510035................................................ 1.2311 18.65
510036................................................ 0.9839 13.20
510038................................................ 1.0640 14.34
510039................................................ 1.3990 16.06
510043................................................ 0.9349 14.29
510046................................................ 1.2735 17.73
510047................................................ 1.2611 19.12
510048................................................ 1.1332 20.37
510050................................................ 1.7457 16.57
510053................................................ 1.0811 15.59
510055................................................ 1.2306 22.84
510058................................................ 1.2795 17.98
510059................................................ 2.0210 16.77
510060................................................ 1.0503 15.66
510061................................................ 1.0243 14.22
510062................................................ 1.2784 17.63
510065................................................ ........ 14.59
510066................................................ ........ 12.72
510067................................................ 1.2058 18.11
510068................................................ 1.2058 16.29
510070................................................ 1.2966 16.36
510071................................................ 1.3297 16.24
510072................................................ 1.0573 17.66
510077................................................ 1.1370 16.41
510080................................................ 1.1479 14.80
510081................................................ 1.0787 13.00
510082................................................ 1.1597 13.69
510084................................................ 1.0361 12.48
510085................................................ 1.2771 18.64
510086................................................ 1.1035 13.79
510088................................................ 1.0389 ......
520002................................................ 1.2721 18.35
520003................................................ 1.0869 16.43
520004................................................ 1.1778 18.17
520006................................................ 1.0164 20.44
520007................................................ 1.0508 13.11
520008................................................ 1.6392 22.80
520009................................................ 1.6949 18.51
520010................................................ 1.1559 20.34
520011................................................ 1.1930 20.38
520013................................................ 1.3680 21.63
520014................................................ 1.1066 16.40
520015................................................ 1.1978 18.32
520016................................................ 0.9703 13.29
520017................................................ 1.1930 19.32
520018................................................ 1.1211 18.64
520019................................................ 1.3095 18.31
520021................................................ 1.4596 20.03
520024................................................ 1.0420 14.61
520025................................................ 1.0654 18.11
520026................................................ 1.0296 19.81
520027................................................ 1.2626 18.91
520028................................................ 1.3294 19.14
520029................................................ 0.8917 16.75
520030................................................ 1.7395 20.00
520031................................................ 1.0756 18.71
520032................................................ 1.2622 17.90
520033................................................ 1.2388 18.89
520034................................................ 1.1058 16.69
520035................................................ 1.3246 17.10
520037................................................ 1.7026 20.05
520038................................................ 1.3352 17.71
520039................................................ 0.9990 19.60
520040................................................ 1.5261 20.74
520041................................................ 1.1567 15.37
520042................................................ 1.1256 17.66
520044................................................ 1.4143 17.79
520045................................................ 1.6556 19.67
520047................................................ 0.9397 17.87
520048................................................ 1.4958 19.17
520049................................................ 2.0506 19.57
520051................................................ 1.8466 19.74
520053................................................ 1.1884 16.49
520054................................................ 1.0542 15.99
520057................................................ 1.1944 18.32
520058................................................ 1.1077 18.13
520059................................................ 1.4368 19.85
520060................................................ 1.4770 17.17
520062................................................ 1.2487 17.80
520063................................................ 1.1864 20.77
520064................................................ 1.5707 21.46
520066................................................ 1.4671 22.44
520068................................................ 0.9618 18.08
520069................................................ 1.2293 17.91
520070................................................ 1.5249 17.82
520071................................................ 1.2525 18.79
520074................................................ 1.0559 18.69
520075................................................ 1.4866 19.09
520076................................................ 1.1796 16.51
520077................................................ 0.9312 15.54
520078................................................ 1.6373 20.56
520082................................................ 1.1943 16.74
520083................................................ 1.7219 22.57
520084................................................ 1.0804 18.95
520087................................................ 1.6992 19.39
520088................................................ 1.2752 20.15
520089................................................ 1.4733 20.61
520090................................................ 1.2604 18.00
520091................................................ 1.2778 20.07
520092................................................ 1.0845 17.56
520094................................................ 0.7818 19.78
520095................................................ 1.2908 18.51
520096................................................ 1.3848 19.30
520097................................................ 1.3197 19.65
520098................................................ 1.7723 20.03
520100................................................ 1.2561 18.38
520101................................................ 1.0650 17.85
520102................................................ 1.1753 19.83
520103................................................ 1.3285 21.23
520107................................................ 1.2649 20.54
520109................................................ 1.0080 18.63
520110................................................ 1.2429 20.03
520111................................................ 1.0771 17.24
520112................................................ 1.1382 18.18
520113................................................ 1.2755 20.59
[[Page 41585]]
520114................................................ 1.0706 17.38
520115................................................ 1.2453 17.38
520116................................................ 1.2751 18.57
520117................................................ 1.0083 17.42
520118................................................ 0.9267 12.44
520120................................................ 0.9639 15.62
520121................................................ 0.9801 17.58
520122................................................ 0.9988 16.76
520123................................................ 0.9687 17.41
520124................................................ 1.0567 16.39
520130................................................ 1.0645 15.16
520131................................................ 1.0215 18.80
520132................................................ 1.2140 17.28
520134................................................ 1.1056 17.61
520135................................................ 0.9686 14.47
520136 *.............................................. 1.5183 19.99
520138................................................ 1.8827 20.89
520139................................................ 1.2600 21.28
520140................................................ 1.6650 21.42
520141................................................ ........ 16.95
520142................................................ 0.8577 17.70
520144................................................ 1.0177 16.62
520145................................................ 0.9103 17.24
520146................................................ 1.0606 15.73
520148................................................ 1.1737 16.93
520149................................................ 0.8651 13.30
520151................................................ 1.0561 18.08
520152................................................ 1.1273 21.33
520153................................................ 0.9014 15.45
520154................................................ 1.1283 17.92
520156................................................ 1.1278 19.84
520157................................................ 1.1408 17.28
520159................................................ 0.9357 18.74
520160................................................ 1.7939 18.84
520161................................................ 0.9978 18.57
520170................................................ 1.1960 22.50
520171................................................ 0.9558 15.73
520173................................................ 1.1310 20.14
520177................................................ 1.7178 21.76
520178................................................ 1.0401 17.04
520187................................................ 0.6853 ......
520188................................................ 1.9479 ......
530002................................................ 1.1799 17.59
530003................................................ 0.8696 15.78
530004................................................ 0.9388 16.19
530005................................................ 1.1268 15.15
530006................................................ 1.1073 19.34
530007................................................ 1.0673 18.06
530008................................................ 1.2158 22.96
530009................................................ 0.9826 19.45
530010................................................ 1.2456 18.93
530011................................................ 1.1585 17.44
530012................................................ 1.6198 19.48
530014................................................ 1.4187 17.32
530015................................................ 1.2855 22.65
530016................................................ 1.2279 17.71
530017................................................ 0.9404 13.71
530018................................................ 0.9876 17.87
530019................................................ 0.9171 16.76
530022................................................ 1.1504 17.88
530023................................................ 0.8235 20.75
530025................................................ 1.3737 20.32
530026................................................ 1.1260 18.92
530027................................................ 0.8284 29.77
530029................................................ 0.9986 17.80
530031................................................ 0.8242 13.38
530032................................................ 1.1799 20.21
------------------------------------------------------------------------
*Asterisk denotes teaching physician costs removed based on costs
reporteorksheet A, Col. 1, Line 23 of FY 1996 cost report.
Table 4a.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
------------------------------------------------------------------------
Wage
Urban area (constituent counties) index GAF
------------------------------------------------------------------------
0040 Abilene, TX................................... 0.8179 0.8714
Taylor, TX
0060 Aguadilla, PR \2\............................. 0.4249 0.5565
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 1.0163 1.0111
Portage, OH
Summit, OH
0120 Albany, GA.................................... 1.0372 1.0253
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY................... 0.8754 0.9129
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM............................... 0.8499 0.8946
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.7910 0.8517
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 0.9550 o.9690
Carbon, PA
LeHigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9342 0.9545
Blair, PA
0320 Amarillo, TX.................................. 0.8435 0.8900
Potter, TX
Randall, TX
0380 Anchorage, AK................................. 1.3009 1.1974
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1483 1.0993
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.8462 0.8919
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.8913 0.9242
Calumet, WI
Outagamie, WI
Winnebago,WI
0470 Arecibo, PR................................... 0.4815 0.6062
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.8884 0.9222
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.9800 0.9863
Clarke, GA
Madison, GA
Oconee, GA
0520 Atlanta, GA................................... 1.0050 1.0034
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......................... 1.1050 1.0708
Atlantic, NJ
Cape May, NJ
0580 Auburn-Opelika, AL............................ 0.7748 0.8397
Lee, AL
0600 Augusta-Aiken, GA-SC.......................... 0.9013 0.9313
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX \1\..................... 0.9081 0.9361
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA \2\........................... 0.9951 0.9966
Kern, CA
0720 Baltimore, MD \1\............................. 0.9891 0.9925
Anne Arundel, MD
Baltimore, MD
Baltimore, City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.................................... 0.9609 0.9731
[[Page 41586]]
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.3302 1.2158
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8707 0.9095
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8624 0.9036
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1394 1.0935
Whatcom, WA
0870 Benton Harbor, MI \2\......................... 0.8831 0.9184
Berrien, MI
0875 Bergen-Passaic, NJ \1\........................ 1.1833 1.1222
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 1.0038 1.0026
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.7949 0.8545
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY................................ 0.8750 0.9126
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.8994 0.9300
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.7893 0.8504
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.8593 0.9014
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.8993 0.9299
McLean, IL
1080 Boise City, ID................................ 0.9086 0.9365
Ada, ID
Canyon, ID
1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA- 1.1369 1.0918
NH (MA Hospitals) \1\ \2\..........................
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA- 1.1358 1.0911
NH (NH Hospitals) \1\..............................
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125 Boulder-Longmont, CO.......................... 0.9944 0.9962
Boulder, CO
1145 Brazoria, TX.................................. 0.8516 0.8958
Brazoria, TX
1150 Bremerton, WA................................. 1.1011 1.0682
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.9212 0.9453
Cameron, TX
1260 Bryan-College Station, TX..................... 0.8501 0.8947
Brazos, TX
1280 \1\ Buffalo-Niagara Falls, NY................ 0.9604 0.9727
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 1.0558 1.0379
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.................................... 0.4561 0.5842
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH \2\...................... 0.8649 0.9054
Carrll, OH
Stark, OH
1350 Casper, WY.................................... 0.9199 0.9444
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.9018 0.9317
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.9163 0.9419
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.8988 0.9295
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9095 0.9371
Kanawha, WV
Putnam, WV
1520 Charlotte-Gastonia-Rock Hill, NC-SC \1\....... 0.9433 0.9608
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 1.0573 1.0389
Albermarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.9731 0.9815
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY 2................................ 0.8859 0.9204
Laramie, WY
1600 Chicago, IL 1................................. 1.0872 1.0589
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................ 1.0390 1.0265
Butte, CA
1640 Cincinnati, OH-KY-IN 1........................ 0.9434 0.9609
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............... 0.8283 0.8790
Christian, KY
Montgomery, TN
1680 Cleveland-Lorain-Elyria, OH 1................. 0.9688 0.9785
[[Page 41587]]
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9218 0.9458
El Paso, CO
1740 Columbia, MO.................................. 0.8904 0.9236
Boone, MO
1760 Columbia, SC.................................. 0.9357 0.9555
Lexington, SC
Richland, SC
1800 Columbus, GA-AL............................... 0.8510 0.8954
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 Columbus, OH.................................. 0.9907 0.9936
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.8702 0.9092
Nueces, TX
San Patricio, TX
1890 Crovallis, OR................................. 1.1087 1.0732
Benton, OR
1900 Cumberland, MD-WV (Maryland Hospitals)........ 0.8801 0.9163
Allegany, MD
Mineral, WV
1920 Dallas, TX 1.................................. 0.9589 0.9717
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.9061 0.9347
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8706 0.9095
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9336 0.9540
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL 2........................... 0.8986 0.9294
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.8679 0.9075
Lawrence, AL
Morgan, AL
2040 Decatur, IL................................... 0.8321 0.8817
Macon, IL
2080 Danver, CO 1.................................. 1.0197 1.0134
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8754 0.9129
Dallas, IA
Polk, IA
Warren, IA
2160 Detroit, MI 1................................. 1.0421 1.0286
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.7836 0.8462
Dale, AL
Houston, AL
2190 Dover, DE..................................... 0.9335 0.9540
Kent, DE
2200 Dubuque, IA................................... 0.8520 0.8961
Dubuque, IA
2240 Duluth-Superior, MN-WI........................ 1.0165 1.0113
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY........................... 0.9872 0.9912
Dutchess, NY
2290 Eau Claire, WI................................ 0.8957 0.9273
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX................................... 0.8947 0.9266
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.9379 0.9570
Elkhart, IN
2335 Elmira, NY \2\................................ 0.8636 0.9045
Chemung, NY
2340 Enid, OK...................................... 0.7953 0.8548
Garfield, OK
2360 Erie, PA...................................... 0.9023 0.9320
Erie, PA
2400 Eugene-Springfield, OR........................ 1.0765 1.0518
Lane, OR
2440 Evansville-Henderson, IN-KY (IN Hospitals) \2\ 0.8396 0.8872
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2440 Evansville-Henderson, IN-KY (KY Hospitals).... 0.8303 0.8804
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN......................... 0.8620 0.9033
Clay, MN
Cass, ND
2560 Fayetteville, NC.............................. 0.8494 0.8942
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.7773 0.8415
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 1.0348 1.0237
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.1020 1.0688
Genesee, MI
2650 Florence, AL.................................. 0.7927 0.8529
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8618 0.9032
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0302 1.0206
Larimer, CO
2680 Ft. Lauderdale, FL \1\........................ 1.0172 1.0117
Broward, FL
2700 Fort Myers-Cape Coral, FL \2\................. 0.8986 0.9294
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 1.0109 1.0075
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.7844 0.8468
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL \2\..................... 0.8986 0.9294
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.9096 0.9372
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 Forth Worth-Arlington, TX \1\................. 0.9835 0.9887
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 1.0262 1.0179
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8754 0.9129
Etowah, AL
2900 Gainesville, FL............................... 1.0102 1.0070
Alachua, FL
2920 Galveston-Texas City, TX...................... 0.9732 0.9816
Galveston, TX
2960 Gary, IN...................................... 0.9369 0.9563
Lake, IN
Porter, IN
2975 Glens Falls, NY \2\........................... 0.8636 0.9045
[[Page 41588]]
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8333 0.8826
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.9097 0.9372
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.9188 0.9437
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI \1\......... 1.0135 1.0092
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 1.0459 1.0312
Cascade, MT
3060 Greeley, CO................................... 0.9722 0.9809
Weld, CO
3080 Green Bay, WI................................. 0.9215 0.9456
Brown, WI
3120 Greensboro-Winston-Salem-High Point, NC 1..... 0.9037 0.9330
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9500 0.9655
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.9188 0.9437
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD................................ 0.8853 0.9200
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.8989 0.9296
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 0.9917 0.9943
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 Hartford, CT \1\ \2\.......................... 1.2413 1.1595
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS \2\........................... 0.7306 0.806
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.9148 0.940
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1479 1.099
Honolulu, HI
3350 Houma, LA..................................... 0.7837 0.8463
Lafourche, LA
Terrebonne, LA
3360 Houston, TX \1\............................... 0.9387 0.9576
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9757 0.9833
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8822 0.9178
Limestone, AL
Madison, AL
3480 Indianapolis, IN \1\.......................... 0.9792 0.9857
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9607 0.9729
Johnson, IA
3520 Jackson, MI................................... 0.8840 0.9190
Jackson, MI
3560 Jackson, MS................................... 0.8387 0.8865
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 0.8600 0.9019
Madison, TN
Chester, TN
3600 Jacksonville, FL \1\ \2\...................... 0.8986 0.9294
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC \2\.......................... 0.8290 0.8795
Onslow, NC
3610 Jamestown, NY \2\............................. 0.8636 0.9045
Chautauqua, NY
3620 Janesville-Beloit, WI......................... 0.9656 0.9763
Rock, WI
3640 Jersey City, NJ............................... 1.1674 1.1118
Hudson, NJ
3660 Johson City-Kingsport-Bristol, TN-VA.......... 0.8894 0.9229
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA \2\............................. 0.8524 0.8964
Cambria, PA
Somerset, PA
3700 Jonesboro, AR................................. 0.7251 0.8024
Craighead, AR
3710 Joplin, MO \2\................................ 0.7723 0.8378
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 0.9981 0.9987
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.8598 0.9017
Kankakee, IL
3760 Kansas City, KS-MO \1\........................ 0.9322 0.9531
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800 Kenosha, WI................................... 0.9033 0.9327
Kenosha, WI
3810 Killeen-Temple, TX............................ 0.9932 0.9953
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.9199 0.9444
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.8984 0.9293
Howard, IN
Tipton, IN
3870 LaCrosse, WI-MN............................... 0.8933 0.9256
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8397 0.8872
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.8809 0.9168
Clinton, IN
Tippecanoa, IN
3960 Lake Charles, LA.............................. 0.7966 0.8558
[[Page 41589]]
Calcasieu, LA
3980 Lakeland-Winter Haven, FL \2\................. 0.8986 0.9294
Polk, FL
4000 Lancaster, PA................................. 0.9255 0.9484
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 0.9977 0.9984
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.................................... 0.8323 0.8819
Webb, TX
4100 Las Cruces, NM................................ 0.8590 0.9012
Dona Anam, NM
4120 Las Vegas, NV-AZ \1\.......................... 1.1258 1.0845
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.8222 0.8745
Douglas, KS
4200 Lawton, OK.................................... 0.9532 0.9677
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.8899 0.9232
Androscoggin, ME
4280 Lexington, KY................................. 0.8552 0.8984
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.9108 0.938
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 0.9670 0.977
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8614 0.9029
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview, Marshall, TX........................ 0.8738 0.9118
Gregg, TX
Harrison, TX
Upshur, TX
4480 Los Angeles-Long Beach, CA \1\................ 1.2085 1.1385
Los Angeles, CA
4520 Louisville, KY-IN............................. 0.9381 0.9572
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8411 0.8883
Lubbock, TX
4640 Lynchburg, VA................................. 0.8814 0.9172
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.8530 0.8968
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 0.9729 0.981
Dane, WI
4800 Mansfield, OH \2\............................. 0.8649 0.905
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4674 0.5940
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8120 0.8671
Hidalgo, TX
4890 Medford-Ashland, OR........................... 1.0492 1.0334
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.9296 0.9512
Brevard, FL
4920 Memphis, TN-AR-MS \1\......................... 0.8244 0.8761
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.................................... 1.0509 1.0346
Merced, CA
5000 Miami, FL \1\................................. 1.0233 1.0159
Dade, FL
5015 Middlesex-Somerset-Hunterdon, NJ \1\.......... 1.0876 1.0592
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 Milwaukee-Waukesha, WI \1\.................... 0.9845 0.9894
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 Minneapolis-St. Paul, MN-WI \1\............... 1.0929 1.0627
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5140 Missoula, MT.................................. 0.9085 0.9364
Missoula, MT
5160 Mobile, AL.................................... 0.8267 0.8778
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0111 1.0076
Stanislaus, CA
5190 Monmouth-Ocean, NJ \1\........................ 1.1258 1.0845
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.................................... 0.8221 0.8745
Quachita, LA
5240 Montgomery, AL................................ 0.7724 0.8379
Autauga, AL
Elmore, AL
Mongomery, AL
5280 Muncie, IN.................................... 1.0834 1.0564
Delaware, IN
5330 Myrtle Beach, SC.............................. 0.8529 0.8968
Horry, SC
5345 Naples, FL.................................... 0.9839 0.9889
Collier, FL
5360 Nashville, TN \1\............................. 0.9449 0.9619
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 Nassau-Suffolk, NY \1\........................ 1.4074 1.2637
Nassau, NY
Suffolk, NY
5483 New Haven-Bridgeport-Stamford-Waterbury- 1.2417 1.1598
Danbury, CT \1\....................................
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT........................ 1.2428 1.1605
New London, CT
5560 New Orleans, LA \1\........................... 0.9089 0.9367
[[Page 41590]]
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 New York, NY \1\.............................. 1.4517 1.2908
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 Newark, NY \1\................................ 1.0772 1.0522
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.0908 1.0613
Orange, NY
Pike, PA
5720 Norfolk-Virginia Beach-Newport News, VA-NC \1\ 0.8442 0.8905
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City VA
Williamsburg City, VA
York, VA
5775 Oakland, CA................................... 1.5095 1.3258
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.9615 0.9735
Marion, FL
5800 Odessa-Midland, TX............................ 0.8873 0.9214
Ector, TX
Midland, TX
5880 Oklahoma City, OK \1\......................... 0.8589 0.9011
Candian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA................................... 1.0932 1.0629
Thurston, WA
5920 Omaha, NE-IA.................................. 1.0455 1.0309
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 Orange County, CA \1\......................... 1.1592 1.1065
Orange, CA
5660 Orlando, FL................................... 0.9806 0.9867
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY................................. 0.8104 0.8659
Daviess, KY
6015 Panama City, FL............................... 0.9169 0.9423
6020 Parkersburg-Marietta, WV-OH (WV Hospitals).... 0.8414 0.8885
Washington, OH
Wood, WV
6020 Parkersburg-Marietta, WV-OH (OH Hospitals) 2.. 0.8649 0.9054
Washington, OH
Wood, WV
6080 Pensacola, FL \2\............................. 0.8986 0.9294
Escambia, FL
Santa Rosa, FL
6120 Peoria-Perkin, IL............................. 0.8399 0.8874
Peoria, IL
Tazewell, IL
Woodford, IL
6160 Philadelphia, PA-NJ........................... 1.1186 1.0798
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 Phoenix-Messa, AZ \1\......................... 0.9464 0.9630
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.7697 0.8359
Jefferson, AR
6280 Pittsburgh, PA \1\............................ 0.9634 0.9748
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA \2\............................ 1.1369 1.0918
Berkshire, MA
6340 Pocatello, ID................................. 0.8973 0.9285
Bannock, ID
6360 Ponce, PR..................................... 0.4971 0.6196
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9487 0.9646
Cumberland, ME
Sagadahoc, ME
York, ME
6440 Portland-Vancouver, OR-WA \1\................. 1.0996 1.0672
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 Providence-Warwick-Pawtucket, RI \1\.......... 1.0690 1.0468
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 0.9818 0.9875
Utah, UT
6560 Pueblo, CO.................................... 0.8853 0.9200
Pueblo, CO
6580 Punta Gorda, FL............................... 0.9508 0.9660
Charalotte, FL
6600 Racine, WI.................................... 0.9216 0.9456
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC \1\............ 0.9544 0.9685
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8363 0.8848
Pennington, SD
6680 Reading, PA................................... 0.9436 0.9610
Berks, PA
6690 Redding, CA................................... 1.1263 1.0849
Shasta, CA
6720 Reno, NV...................................... 1.0655 1.0444
Washoe, NV
6740 Richland-Kennewick-Pasco, WA.................. 1.1224 1.0823
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 0.9545 0.9686
[[Page 41591]]
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780 Riverside-San Bernardino, CA \1\.............. 1.1061 1.0715
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA 0.8142 0.8687
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.1429 1.0958
Olmsted, MN
6840 Rochester, NY \1\............................. 0.9184 0.9434
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.8783 0.9150
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.8735 0.9115
Edgecombe, NC
Nash, NC
6920 Sacramento, CA \1\............................ 1.2284 1.1513
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9294 0.9511
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9608 0.9730
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.8943 0.9264
Andrew, MO
Buchanan, MO
7040 St. Louis, MO-IL \1\.......................... 0.9052 0.9341
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080 Salem, OR..................................... 0.9949 0.9965
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.4710 1.3025
Monterey, CA
7160 Salt Lake City-Ogden, UT \1\.................. 0.9854 0.9900
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.7845 0.8469
Tom Green, TX
7240 San Antonio, TX \1\........................... 0.8318 0.8815
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 San Diego, CA \1\............................. 1.1955 1.1301
San Diego, CA
7360 San Francisco, CA \1\......................... 1.3784 1.2458
Marin, CA
San Francisco, CA
San Mateo, CA
7400 San Jose, CA \1\.............................. 1.3492 1.2277
Santa Clara, CA
7440 San Juan-Bayamon, PR \1\...................... 0.4657 0.5925
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.... 1.0470 1.0320
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.0819 1.0554
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.3927 1.2546
Santa Cruz, CA
7490 Santa Fe, NM.................................. 1.0437 1.0297
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA................................ 1.3000 1.1968
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 0.9905 0.9935
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 0.9953 0.9968
Bryan, GA
Chatham, GA
Effington, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA \2\...... 0.8524 0.8964
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 Seattle-Bellevue-Everett, WA \1\.............. 1.1289 1.0866
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA \2\................................ 0.8524 0.8964
[[Page 41592]]
Mercer, PA
7620 Sheboygan, WI \2\............................. 0.8759 0.9133
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.9329 0.9535
Grayson, TX
7680 Shreveport-Bossier City, LA................... 0.9049 0.9339
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8549 0.8982
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD............................... 0.8776 0.9145
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................ 0.9793 0.9858
St. Joseph, IN
7840 Spokane, WA................................... 1.0799 1.0541
Spokane, WA
7880 Springfield, IL............................... 0.8684 0.9079
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.7991 0.8576
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA \2\........................... 1.1369 1.0918
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.9138 0.9401
Centre, PA
8080 Steubenville-Weirton, OH-WV (OH Hospitals) \2\ 0.8649 0.9054
Jefferson, OH
Brooke, WV
Hancock, WV
8080 Steubenville-Weirton, OH-WV (OH Hospitals) \2\ 0.8614 0.9029
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.0518 1.0352
San Joaquin, CA
8140 Sumter, SC \2\................................ 0.8264 0.8776
Sumter, SC
8160 Syracuse, NY.................................. 0.9441 0.9614
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.................................... 1.1631 1.1090
Pierce, WA
8240 Tallahassee, FL \2\........................... 0.8986 0.9294
Gadsden, FL
Leon, FL
8280 Tampa-St. Petersburg-Clearwater, FL \1\....... 0.9119 0.9388
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN............................... 0.8570 0.8997
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX................... 0.8174 0.8710
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 0.9593 0.9719
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 0.9326 0.9533
Shawnee, KS
8480 Trenton, NJ................................... 0.9955 0.9969
Mercer, NJ
8520 Tucson, AZ.................................... 0.8742 0.9120
Pima, AZ
8560 Tulsa, OK..................................... 0.8086 0.8646
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................ 0.8064 0.8630
Tuscaloosa, AL
8640 Tyler, TX..................................... 0.9369 0.9563
Smith, TX
8680 Utica-Rome, NY \2\............................ 0.8636 0.9045
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.2655 1.1750
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.0952 1.0643
Ventura, CA
8750 Victoria, TX.................................. 0.8378 0.8859
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 1.0517 1.0351
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA................ 1.0411 1.0280
Tulare, CA
8800 Waco, TX...................................... 0.8075 0.8638
McLennan, TX
8840 Washington, DC-MD-VA-WV \1\................... 1.1053 1.0710
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...................... 0.8841 0.9191
Black Hawk, IA
8940 Wausau, WI.................................... 0.9445 0.9617
Marathon, WI
8960 West Palm Beach-Boca Raton, FL \1\,\2\........ 0.9951 0.9966
Palm Beach, FL
9000 Wheeling, WV-OH (WV Hospitals) \2\............ 0.8068 0.8633
Belmont, OH
Marshall, WV
Ohio, WV
9000 Wheeling, WV-OH (OH Hospitals) \2\............ 0.8649 0.9054
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.9421 0.09600
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.7652 0.8325
Archer, TX
Wichita, TX
9140 Williamsport, PA \2\.......................... 0.8524 0.8964
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.1274 1.0856
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9707 0.9798
New Hanover, NC
Brunswick, NC
9260 \2\ Yakima, WA................................ 1.0446 1.0303
[[Page 41593]]
Yakima, WA
9270 Yolo, CA...................................... 1.0485 1.0330
Yolo, CA
9280 York, PA...................................... 0.9309 0.9521
York, PA
9320 Youngstown-Warren, OH......................... 0.9996 0.9997
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0662 1.0449
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 0.9924 0.9948
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 Capitla Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7390 0.8129
Alaska.............................................. 1.2057 1.1367
Arizona............................................. 0.8544 0.8978
Arkansas............................................ 0.7236 0.8013
California.......................................... 0.9951 0.9966
Colorado............................................ 0.8813 0.9171
Connecticut......................................... 1.2413 1.1595
Delaware............................................ 0.9166 0.9421
Florida............................................. 0.8986 0.9294
Georgia............................................. 0.8094 0.8652
Hawaii.............................................. 1.0726 1.0492
Idaho............................................... 0.8651 0.9055
Illinois............................................ 0.8047 0.8617
Indiana............................................. 0.8396 0.8872
Iowa................................................ 0.7926 0.8528
Kansas.............................................. 0.7460 0.8182
Kentucky............................................ 0.8043 0.8615
Louisiana........................................... 0.7486 0.8201
Maine............................................... 0.8639 0.9047
Maryland............................................ 0.8631 0.9041
Massachusetts....................................... 1.1369 1.0918
Michigan............................................ 0.8831 0.9184
Minnesota........................................... 0.8669 0.9068
Mississippi......................................... 0.7306 0.8066
Missouri............................................ 0.7723 0.8378
Montana............................................. 0.8398 0.8873
Nebraska............................................ 0.8007 0.8588
Nevada.............................................. 0.9097 0.9372
New Hampshire....................................... 0.9905 0.9935
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.8378 0.8859
New York............................................ 0.8636 0.9045
North Carolina...................................... 0.8290 0.8795
North Dakota........................................ 0.7647 0.8322
Ohio................................................ 0.8649 0.9054
Oklahoma............................................ 0.7255 0.8027
Oregon.............................................. 0.9873 0.9913
Pennsylvania........................................ 0.8524 0.8964
Puerto Rico......................................... 0.4249 0.5565
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.8264 0.8776
South Dakota........................................ 0.7576 0.8269
Tennessee........................................... 0.7650 0.8324
Texas............................................... 0.7471 0.8190
Utah................................................ 0.8906 0.9237
Vermont............................................. 0.9427 0.9604
Virginia............................................ 0.7916 0.8521
Washington.......................................... 1.0446 1.0303
West Virginia....................................... 0.8068 0.8633
Wisconsin........................................... 0.8759 0.9133
Wyoming............................................. 0.8859 0.9204
------------------------------------------------------------------------
\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......................................... 0.8179 0.8714
Akron, OH........................................... 0.9981 0.9987
Albany, GA.......................................... 0.9544 0.9685
Alexandria, LA...................................... 0.7910 0.8517
Amarillo, TX........................................ 0.8435 0.8900
Anchorage, AK....................................... 1.3009 1.1974
Ann Arbor, MI....................................... 1.1343 1.0901
Atlanta, GA......................................... 1.0050 1.0034
Austin-San Marcos, TX............................... 0.9081 0.9361
Baltimore, MD....................................... 0.9891 0.9925
Baton Rouge, LA..................................... 0.8707 0.9095
Beaumont-Port Arthur, TX............................ 0.8624 0.9036
Benton Harbor, MI................................... 0.8831 0.9184
Bergen-Passaic, NJ.................................. 1.1833 1.1222
Billings, MT........................................ 1.0038 1.0026
Biloxi-Gulfport-Pascagoula, MS...................... 0.7949 0.8545
Binghamton, NY...................................... 0.8750 0.9126
Birmingham, AL...................................... 0.8994 0.9300
Bismarck, ND........................................ 0.7893 0.8504
Boise City, ID...................................... 0.9086 0.9365
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1358 1.0911
Burlington, VT...................................... 1.0122 1.0083
Caguas, PR.......................................... 0.4561 0.5842
Champaign-Urbana, IL................................ 0.9163 0.9419
Charleston-North Charleston, SC..................... 0.8988 0.9295
Charleston, WV...................................... 0.8861 0.9205
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9433 0.9608
Chattanooga, TN-GA.................................. 0.9453 0.9622
Chicago, IL......................................... 1.0872 1.0589
Cincinnati, OH-KY-IN................................ 0.9434 0.9609
Clarksville-Hopkinsville, TN-KY..................... 0.8283 0.8790
Cleveland-Lorain-Elyria, OH......................... 0.9688 0.9785
Columbia, MO........................................ 0.8736 0.9116
Columbia, SC........................................ 0.9215 0.9456
Columbus, GA-AL..................................... 0.8318 0.8815
Columbus, OH........................................ 0.9728 0.9813
Corpus Christi, TX.................................. 0.8599 0.9018
Dallas, TX.......................................... 0.9589 0.9717
Danville, VA........................................ 0.8706 0.9095
Davenport-Moline-Rock Island, IA-IL................. 0.8606 0.9023
Dayton-Springfield, OH.............................. 0.9231 0.9467
Denver, CO.......................................... 1.0197 1.0134
Des Moines, IA...................................... 0.8754 0.9129
Dothan, AL.......................................... 0.7836 0.8462
Dover, DE........................................... 1.0511 1.0347
Duluth-Superior, MN-WI.............................. 1.0165 1.0113
Elkhart-Goshen, IN.................................. 0.9379 0.9570
Eugene-Springfield, OR.............................. 1.0765 1.0518
Evansville-Henderson, IN-KY......................... 0.8396 0.8872
Fargo-Moorhead, ND-MN (ND and SD Hospitals)......... 0.8620 0.9033
Fargo-Moorhead, ND-MN (MN Hospital)................. 0.8669 0.9068
Fayetteville, NC.................................... 0.8494 0.8942
Flagstaff, AZ-UT.................................... 0.9860 0.9904
Flint, MI........................................... 1.0918 1.0620
Fort Collins-Loveland, CO........................... 1.0197 1.0134
Fort Pierce-Port St. Lucie, FL...................... 1.0109 1.0075
Fort Smith, AR-OK................................... 0.7696 0.8358
Fort Walton Beach, FL............................... 0.8713 0.9100
Forth Worth-Arlington, TX........................... 0.9835 0.9887
Fresno, CA.......................................... 1.0262 1.0179
Gadsden, AL......................................... 0.8754 0.9129
Gainesville, FL..................................... 0.9963 0.9975
Goldsboro, NC....................................... 0.8333 0.8826
Grand Forks, ND-MN.................................. 0.9097 0.9372
Grand Rapids-Muskegon-Holland, MI................... 1.0017 1.0012
Great Falls, MT..................................... 1.0459 1.0312
Greeley, CO......................................... 0.9449 0.9619
Green Bay, WI....................................... 0.9215 0.9456
Greensboro-Winston-Salem-High Point, NC............. 0.9037 0.9330
Greenville, NC...................................... 0.9237 0.9471
Greenville-Spartanburg-Anderson, SC................. 0.9188 0.9437
Hagerstown, MD...................................... 0.8853 0.9200
Harrisburg-Lebanon-Carlisle, PA..................... 0.9793 0.9858
Hartford, CT........................................ 1.1715 1.1145
Hickory-Morganton-Lenoir, NC........................ 0.9148 0.9408
Honolulu, HI........................................ 1.1479 1.0991
Houston, TX......................................... 0.9387 0.9576
Huntington-Ashland, WV-KY-OH........................ 0.9436 0.9610
Huntsville, AL...................................... 0.8608 0.9024
Indianapolis, IN.................................... 0.9792 0.9857
Iowa City, IA....................................... 0.9460 0.9627
Jackson, MS......................................... 0.8268 0.8779
Jackson, TN......................................... 0.8447 0.8909
Jacksonville, FL.................................... 0.8957 0.9273
Johnson City-Kingsport-Bristol, TN-VA............... 0.8894 0.9229
Jonesboro, AR....................................... 0.7251 0.8024
Joplin, MO.......................................... 0.7678 0.8345
[[Page 41594]]
Kalamazoo-Battlecreek, MI........................... 0.9981 0.9987
Kansas City, KS-MO.................................. 0.9322 0.9531
Knoxville, TN....................................... 0.9199 0.9444
Kokomo, IN.......................................... 0.8984 0.9293
Lafayette, LA....................................... 0.8397 0.8872
Lansing-East Lansing, MI............................ 0.9834 0.9886
Las Vegas, NV-AZ.................................... 1.1258 1.0845
Lexington, KY....................................... 0.8552 0.8984
Lima, OH............................................ 0.9108 0.9380
Lincoln, NE......................................... 0.9451 0.9621
Little Rock-North Little Rock, AR................... 0.8432 0.8898
Longview-Marshall, TX............................... 0.8541 0.8976
Los Angeles-Long Beach, CA.......................... 1.2085 1.1385
Louisville, KY-IN................................... 0.9381 0.9572
Macon, GA........................................... 0.8530 0.8968
Madison, WI......................................... 0.9729 0.9814
Mansfield, OH....................................... 0.8649 0.9054
Memphis, TN-AR-MS................................... 0.8244 0.8761
Merced, CA.......................................... 1.0509 1.0346
Milwaukee-Waukesha, WI.............................. 0.9845 0.9894
Minneapolis-St. Paul, MN-WI......................... 1.0929 1.0627
Missoula, MT........................................ 0.9085 0.9364
Monmouth-Ocean, NJ.................................. 1.1258 1.0845
Monroe, LA.......................................... 0.8062 0.8628
Montgomery, AL...................................... 0.7724 0.8379
Myrtle Beach, SC.................................... 0.8357 0.8843
Nashville, TN....................................... 0.9254 0.9483
New Haven-Bridgeport-Stamford-Waterbury- Danbury, CT 1.2417 1.1598
New London-Norwich, CT.............................. 1.2328 1.1541
New Orleans, LA..................................... 0.9089 0.9367
New York, NY........................................ 1.4399 1.2836
Newark, NJ.......................................... 1.0772 1.0522
Newburgh, NY-PA..................................... 1.0837 1.0566
Norfolk-Virginia Beach-Newport News, VA-NC.......... 0.8442 0.8905
Oakland, CA......................................... 1.5095 1.3258
Oklahoma City, OK................................... 0.8589 0.9011
Omaha, NE-IA........................................ 1.0455 1.0309
Orange County, CA................................... 1.1592 1.1065
Orlando, FL......................................... 0.9806 0.9867
Peoria-Pekin, IL.................................... 0.8399 0.8874
Philadelphia, PA-NJ................................. 1.1186 1.0798
Phoenix-Mesa, AZ.................................... 0.9464 0.9630
Pittsburgh, PA...................................... 0.9496 0.9652
Pocatello, ID....................................... 0.8651 0.9055
Portland, ME........................................ 0.9487 0.9646
Portland-Vancouver, OR-WA........................... 1.0996 1.0672
Provo-Orem, UT...................................... 0.9818 0.9875
Raleigh-Durham-Chapel Hill, NC...................... 0.9544 0.9685
Roanoke, VA......................................... 0.8142 0.8687
Rockford, IL........................................ 0.8783 0.9150
Sacramento, CA...................................... 1.2284 1.1513
Saginaw-Bay City-Midland, MI........................ 0.9294 0.9511
St. Cloud, MN....................................... 0.9608 0.9730
St. Louis, MO-IL.................................... 0.9052 0.9341
Salt Lake City-Ogden, UT............................ 0.9854 0.9900
San Diego, CA....................................... 1.1955 1.1301
Santa Fe, NM........................................ 0.9911 0.9939
Santa Rosa, CA...................................... 1.3000 1.1968
Seattle-Bellevue-Everett, WA........................ 1.1289 1.0866
Sharon, PA.......................................... 0.8524 0.8964
Sherman-Denison, TX................................. 0.8833 0.9185
Sioux City, IA-NE................................... 0.8549 0.8982
South Bend, IN...................................... 0.9692 0.9788
Springfield, IL..................................... 0.8684 0.9079
Springfield, MO..................................... 0.7991 0.8576
Syracuse, NY........................................ 0.9441 0.9614
Tallahassee, FL..................................... 0.8274 0.8783
Tampa-St. Petersburg-Clearwater, FL................. 0.9119 0.9388
Texarkana, AR-Texarkana, TX......................... 0.8174 0.8710
Toledo, OH.......................................... 0.9593 0.9719
Topeka, KS.......................................... 0.9326 0.9533
Tulsa, OK........................................... 0.7931 0.8532
Tuscaloosa, AL...................................... 0.8064 0.8630
Tyler, TX........................................... 0.9199 0.9444
Vallejo-Fairfield-Napa, CA.......................... 1.2167 1.1438
Victoria, TX........................................ 0.8378 0.8859
Waco, TX............................................ 0.8075 0.8638
Washington, DC-MD-VA-WV............................. 1.1053 1.0710
Waterloo-Cedar Falls, IA............................ 0.8841 0.9191
Wausau, WI.......................................... 0.9445 0.9617
Wichita, KS......................................... 0.9082 0.9362
Rural Colorado...................................... 0.8813 0.9171
Rural Florida....................................... 0.8986 0.9294
Rural Illinois...................................... 0.8047 0.8617
Rural Louisiana..................................... 0.7486 0.8201
Rural Michigan...................................... 0.8831 0.9184
Rural Minnesota..................................... 0.8669 0.9068
Rural Missouri...................................... 0.7723 0.8378
Rural Montana....................................... 0.8398 0.8873
Rural Oregon........................................ 0.9873 0.9913
Rural Tennessee..................................... 0.7650 0.8324
Rural Texas......................................... 0.7471 0.8190
Rural Virginia (KY Hospital)........................ 0.8043 0.8615
Rural Washington.................................... 1.0333 1.0227
Rural Wyoming....................................... 0.8859 0.9204
------------------------------------------------------------------
Table 4d.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 17.3227
Aguadilla, PR................................................ 8.0776
Akron, OH.................................................... 21.5248
Albany, GA................................................... 21.9678
Albany-Schenectady-Troy, NY.................................. 18.5415
Albuquerque, NM.............................................. 18.0017
Alexandria, LA............................................... 16.6660
Allentown-Bethlehem-Easton, PA............................... 21.6602
Altoona, PA.................................................. 19.7859
Amarillo, TX................................................. 17.7501
Anchorage, AK................................................ 27.2347
Ann Arbor, MI................................................ 24.3199
Anniston, AL................................................. 17.9235
Appleton-Oshkosh-Neenah, WI.................................. 18.8767
Arecibo, PR.................................................. 10.1973
Asheville, NC................................................ 18.8155
Athens, GA................................................... 20.5536
Atlanta, GA.................................................. 21.2868
Atlantic-Cape May, NJ........................................ 23.9544
Auburn-Opelika, AL........................................... 16.4103
Augusta-Aiken, GA-SC......................................... 19.0900
Austin-San Marcos, TX........................................ 19.2341
Bakersfield, CA.............................................. 20.3699
Baltimore, MD................................................ 20.9485
Bangor, ME................................................... 20.3521
Barnstable-Yarmouth, MA...................................... 28.1731
Baton Rouge, LA.............................................. 18.4424
Beaumont-Port Arthur, TX..................................... 18.2648
Bellingham, WA............................................... 24.1321
Benton Harbor, MI............................................ 17.9119
Bergen-Passaic, NJ........................................... 25.4749
Billings, MT................................................. 21.2596
Biloxi-Gulfport-Pascagoula, MS............................... 16.6634
Binghamton, NY............................................... 18.5327
Birmingham, AL............................................... 19.0492
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............. 24.0562
Boulder-Longmont, CO......................................... 21.0610
Brazoria, TX................................................. 18.0362
Bremerton, WA................................................ 23.3211
Brownsville-Harlingen-San Benito, TX......................... 19.5103
Bryan-College Station, TX.................................... 18.0042
Buffalo-Niagara Falls, NY.................................... 20.3404
Burlington, VT............................................... 22.3616
Caguas, PR................................................... 9.6595
Canton-Massillon, OH......................................... 18.5769
Casper, WY................................................... 19.4829
Cedar Rapids, IA............................................. 19.1010
Champaign-Urbana, IL......................................... 19.4065
Charleston-North Charleston, SC.............................. 19.0373
Charleston, WV............................................... 19.2624
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 19.9800
Charlottesville, VA.......................................... 22.3946
Chattanooga, TN-GA........................................... 20.6102
Cheyenne, WY................................................. 17.3158
Chicago, IL.................................................. 23.0278
Chico-Paradise, CA........................................... 22.0066
Cincinnati, OH-KY-IN......................................... 19.9480
Clarksville-Hopkinsville, TN-KY.............................. 17.1337
Cleveland-Lorain-Elyria, OH.................................. 20.5190
Colorado Springs, CO......................................... 19.5228
Columbia, MO................................................. 18.8596
Columbia, SC................................................. 19.8182
Columbus, GA-AL.............................................. 18.0250
Columbus, OH................................................. 20.9839
Corpus Christi, TX........................................... 18.4298
Corvallis, OR................................................ 23.4819
Cumberland, MD-WV............................................ 18.6405
Dallas, TX................................................... 20.3455
Danville, VA................................................. 19.1906
Davenport-Moline-Rock Island, IA-IL.......................... 18.4403
[[Page 41595]]
Dayton-Springfield, OH....................................... 20.0366
Daytona Beach, FL............................................ 19.0345
Decatur, AL.................................................. 18.3823
Decatur, IL.................................................. 17.6232
Denver, CO................................................... 21.5811
Des Moines, IA............................................... 18.5408
Detroit, MI.................................................. 22.0711
Dothan, AL................................................... 16.5159
Dover, DE.................................................... 19.7725
Dubuque, IA.................................................. 18.0451
Duluth-Superior, MN-WI....................................... 21.5294
Dutchess County, NY.......................................... 22.3487
Eau Claire, WI............................................... 18.9711
El Paso, TX.................................................. 18.9500
Elkhart-Goshen, IN........................................... 19.8656
Elmira, NY................................................... 18.0730
Enid, OK..................................................... 16.8452
Erie, PA..................................................... 19.1114
Eugene-Springfield, OR....................................... 22.4571
Evansville, Henderson, IN-KY................................. 17.5854
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................................................. 18.2536
Fort Collins-Loveland, CO.................................... 21.8189
Fort Lauderdale, FL.......................................... 21.5452
Fort Myers-Cape Coral, FL.................................... 18.9574
Fort Pierce-Port St. Lucie, FL............................... 21.1766
Fort Smith, AR-OK............................................ 16.6129
Fort Walton Beach, FL........................................ 18.4550
Fort Wayne, IN............................................... 19.2662
Fort Worth-Arlington, TX..................................... 20.8308
Fresno, CA................................................... 21.7350
Gadsden, AL.................................................. 18.4020
Gainesville, FL.............................................. 21.3966
Galveston-Texas City, TX..................................... 20.6131
Gary, IN..................................................... 19.8884
Glens Falls, NY.............................................. 18.2277
Goldsboro, NC................................................ 17.6500
Grand Forks, ND-MN........................................... 19.2683
Grand Junction, CO........................................... 19.4593
Grand Rapids-Muskegon-Holland, MI............................ 21.4652
Great Falls, MT.............................................. 22.1512
Greeley, CO.................................................. 20.5908
Green Bay, WI................................................ 19.3420
Greensboro-Winston-Salem-High Point, NC...................... 19.1402
Greenville, NC............................................... 20.1214
Greenville-Spartanburg-Anderson, SC.......................... 19.4594
Hagerstown, MD............................................... 18.7266
Hamilton-Middletown, OH...................................... 18.9474
Harrisburg-Lebanon-Carlisle, PA.............................. 21.0037
Hartford, CT................................................. 24.8124
Hattiesburg, MS.............................................. 16.1679
Hickory-Morganton-Lenoir, NC................................. 19.2995
Honolulu, HI................................................. 24.3050
Houma, LA.................................................... 16.5978
Houston, TX.................................................. 19.8810
Huntington-Ashland, WV-KY-OH................................. 20.6646
Huntsville, AL............................................... 18.6860
Indianapolis, IN............................................. 20.7402
Iowa City, IA................................................ 20.3481
Jackson, MI.................................................. 18.7230
Jackson, MS.................................................. 17.7627
Jackson, TN.................................................. 18.2151
Jacksonville, FL............................................. 18.9712
Jacksonville, NC............................................. 16.6300
Jamestown, NY................................................ 16.6418
Janesville-Beloit, WI........................................ 20.4504
Jersey City, NJ.............................................. 24.7265
Johnson City-Kingsport-Bristol, TN-VA........................ 18.7506
Johnstown, PA................................................ 18.2989
Jonesboro, AR................................................ 15.3149
Joplin, MO................................................... 16.2618
Kalamazoo-Battlecreek, MI.................................... 21.1395
Kankakee, IL................................................. 18.2109
Kansas City, KS-MO........................................... 19.7430
Kenosha, WI.................................................. 19.1315
Killeen-Temple, TX........................................... 21.0356
Knoxville, TN................................................ 19.4838
Kokomo, IN................................................... 18.8885
La Crosse, WI-MN............................................. 18.9205
Lafayette, LA................................................ 17.6615
Lafayette, IN................................................ 18.6572
Lake Charles, LA............................................. 16.8715
Lakeland-Winter Haven, FL.................................... 18.6713
Lancaster, PA................................................ 19.6017
Lansing-East Lansing, MI..................................... 21.1315
Laredo, TX................................................... 17.6272
Las Cruces, NM............................................... 18.1944
Las Vegas, NV-AZ............................................. 23.8445
Lawrence, KS................................................. 17.4151
Lawton, OK................................................... 20.1897
Lewiston-Auburn, ME.......................................... 18.8489
Lexington, KY................................................ 18.0690
Lima, OH..................................................... 18.8613
Lincoln, NE.................................................. 20.4820
Little Rock-North Little Rock, AR............................ 18.2444
Longview-Marshall, TX........................................ 18.5072
Los Angeles-Long Beach, CA................................... 25.5235
Louisville, KY-IN............................................ 19.8685
Lubbock, TX.................................................. 17.8142
Lynchburg, VA................................................ 18.6683
Macon, GA.................................................... 18.0675
Madison, WI.................................................. 20.6054
Mansfield, OH................................................ 17.9510
Mayaguez, PR................................................. 9.9005
McAllen-Edinburg-Mission, TX................................. 17.1975
Medford-Ashland, OR.......................................... 22.2214
Melbourne-Titusville-Palm Bay, FL............................ 19.6889
Memphis, TN-AR-MS............................................ 17.4610
Merced, CA................................................... 21.7673
Miami, FL.................................................... 21.6737
Middlesex-Somerset-Hunterdon, NJ............................. 23.5556
Milwaukee-Waukesha, WI....................................... 20.8513
Minneapolis-St. Paul, MN-WI.................................. 23.1482
Missoula, MT................................................. 19.2420
Mobile, AL................................................... 17.5090
Modesto, CA.................................................. 21.4157
Monmouth-Ocean, NJ........................................... 23.8439
Monroe, LA................................................... 17.4115
Montgomery, AL............................................... 16.3157
Muncie, IN................................................... 22.9458
Myrtle Beach, SC............................................. 18.0643
Naples, FL................................................... 20.8392
Nashville, TN................................................ 20.0138
Nassau-Suffolk, NY........................................... 29.8096
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 26.1700
New London-Norwich, CT....................................... 26.3222
New Orleans, LA.............................................. 19.2503
New York, NY................................................. 30.7475
Newark, NJ................................................... 24.6654
Newburgh, NY-PA.............................................. 23.1041
Norfolk-Virginia Beach-Newport News, VA-NC................... 17.8754
Oakland, CA.................................................. 31.8928
Ocala, FL.................................................... 20.3639
Odessa-Midland, TX........................................... 18.7922
Oklahoma City, OK............................................ 18.1873
Olympia, WA.................................................. 23.1536
Omaha, NE-IA................................................. 22.1432
Orange County, CA............................................ 24.5477
Orlando, FL.................................................. 20.7465
Owensboro, KY................................................ 17.1643
Panama City, FL.............................................. 19.4197
Parkersburg-Marietta, WV-OH.................................. 17.8217
Pensacola, FL................................................ 17.8801
Peoria-Pekin, IL............................................. 17.6840
Philadelphia, PA-NJ.......................................... 23.6372
Phoenix-Mesa, AZ............................................. 20.0450
Pine Bluff, AR............................................... 16.3022
Pittsburgh, PA............................................... 20.4057
Pittsfield, MA............................................... 21.7194
Pocatello, ID................................................ 19.0047
Ponce, PR.................................................... 10.5280
Portland, ME................................................. 20.0674
Portland-Vancouver, OR-WA.................................... 23.2438
Providence-Warwick, RI....................................... 22.6420
Provo-Orem, UT............................................... 20.7946
Pueblo, CO................................................... 18.7505
Punta Gorda, FL.............................................. 20.1370
Racine, WI................................................... 19.5201
Raleigh-Durham-Chapel Hill, NC............................... 20.2151
Rapid City, SD............................................... 17.7126
Reading, PA.................................................. 19.9855
Redding, CA.................................................. 23.8559
Reno, NV..................................................... 22.5678
Richland-Kennewick-Pasco, WA................................. 23.7721
Richmond-Petersburg, VA...................................... 20.2158
Riverside-San Bernardino, CA................................. 23.7428
Roanoke, VA.................................................. 17.2365
Rochester, MN................................................ 24.2072
Rochester, NY................................................ 19.4510
Rockford, IL................................................. 18.6017
Rocky Mount, NC.............................................. 18.4997
Sacramento, CA............................................... 26.0168
Saginaw-Bay City-Midland, MI................................. 19.6689
St. Cloud, MN................................................ 19.9529
St. Joseph, MO............................................... 18.9408
St. Louis, MO-IL............................................. 19.1725
Salem, OR.................................................... 21.0721
Salinas, CA.................................................. 31.1554
Salt Lake City-Ogden, UT..................................... 20.8711
San Angelo, TX............................................... 16.6166
San Antonio, TX.............................................. 17.6168
San Diego, CA................................................ 25.2676
San Francisco, CA............................................ 29.6537
San Jose, CA................................................. 28.8225
San Juan-Bayamon, PR......................................... 9.8640
San Luis Obispo-Atascadero-Paso Robles, CA................... 22.1746
Santa Barbara-Santa Maria-Lompoc, CA......................... 22.9137
Santa Cruz-Watsonville, CA................................... 29.4979
Santa Fe, NM................................................. 22.1051
Santa Rosa, CA............................................... 27.5337
Sarasota-Bradenton, FL....................................... 20.9796
Savannah, GA................................................. 21.0803
[[Page 41596]]
Scranton-Wilkes Barre-Hazleton, PA........................... 17.7324
Seattle-Bellevue-Everett, WA................................. 23.9115
Sharon, PA................................................... 17.5441
Sheboygan, WI................................................ 17.3719
Sherman-Denison, TX.......................................... 19.7582
Shreveport-Bossier City, LA.................................. 19.1657
Sioux City, IA-NE............................................ 18.1059
Sioux Falls, SD.............................................. 18.5874
South Bend, IN............................................... 20.7421
Spokane, WA.................................................. 22.8719
Springfield, IL.............................................. 18.3917
Springfield, MO.............................................. 16.9245
Springfield, MA.............................................. 22.6142
State College, PA............................................ 19.3540
Steubenville-Weirton, OH-WV.................................. 18.2449
Stockton-Lodi, CA............................................ 22.2772
Sumter, SC................................................... 17.4486
Syracuse, NY................................................. 19.9343
Tacoma, WA................................................... 24.3099
Tallahassee, FL.............................................. 17.9690
Tampa-St. Petersburg-Clearwater, FL.......................... 19.1546
Terre Haute, IN.............................................. 18.1515
Texarkana, AR-Texarkana, TX.................................. 17.2300
Toledo, OH................................................... 20.7884
Topeka, KS................................................... 19.7520
Trenton, NJ.................................................. 21.3959
Tucson, AZ................................................... 18.5157
Tulsa, OK.................................................... 17.1256
Tuscaloosa, AL............................................... 17.0793
Tyler, TX.................................................... 19.8429
Utica-Rome, NY............................................... 17.5752
Vallejo-Fairfield-Napa, CA................................... 28.2652
Ventura, CA.................................................. 24.2606
Victoria, TX................................................. 17.7441
Vineland-Millville-Bridgeton, NJ............................. 22.2740
Visalia-Tulare-Porterville, CA............................... 22.0500
Waco, TX..................................................... 17.1037
Washington, DC-MD-VA-WV...................................... 23.4111
Waterloo-Cedar Falls, IA..................................... 18.0392
Wausau, WI................................................... 20.0043
West Palm Beach-Boca Raton, FL............................... 21.2055
Wheeling, OH-WV.............................................. 16.1892
Wichita, KS.................................................. 19.9536
Wichita Falls, TX............................................ 16.2079
Williamsport, PA............................................. 17.8945
Wilmington-Newark, DE-MD..................................... 23.8786
Wilmington, NC............................................... 20.5594
Yakima, WA................................................... 21.8833
Yolo, CA..................................................... 20.5840
York, PA..................................................... 19.7168
Youngstown-Warren, OH........................................ 21.1707
Yuba City, CA................................................ 22.5818
Yuma, AZ..................................................... 21.0182
------------------------------------------------------------------------
Table 4e.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
Average
Nonurban area hourly
wage
------------------------------------------------------------------------
Alabama...................................................... 15.6529
Alaska....................................................... 25.5370
Arizona...................................................... 18.0961
Arkansas..................................................... 15.3250
California................................................... 21.0766
Colorado..................................................... 18.6657
Connecticut.................................................. 26.2903
Delaware..................................................... 19.4135
Florida...................................................... 19.0317
Georgia...................................................... 17.1426
Hawaii....................................................... 22.7187
Idaho........................................................ 18.3238
Illinois..................................................... 17.0445
Indiana...................................................... 17.7834
Iowa......................................................... 16.7882
Kansas....................................................... 15.8000
Kentucky..................................................... 17.0342
Louisiana.................................................... 15.6336
Maine........................................................ 18.2971
Maryland..................................................... 18.2815
Massachusetts................................................ 24.0785
Michigan..................................................... 18.6693
Minnesota.................................................... 18.3602
Mississippi.................................................. 15.4749
Missouri..................................................... 16.3576
Montana...................................................... 17.7804
Nebraska..................................................... 16.9591
Nevada....................................................... 19.2681
New Hampshire................................................ 20.9790
New Jersey \1\...............................................
New Mexico................................................... 17.7448
New York..................................................... 18.2911
North Carolina............................................... 17.5573
North Dakota................................................. 16.1967
Ohio......................................................... 18.3192
Oklahoma..................................................... 15.3668
Oregon....................................................... 20.8991
Pennsylvania................................................. 18.0541
Puerto Rico.................................................. 8.9988
Rhode Island \1\.............................................
South Carolina............................................... 17.5024
South Dakota................................................. 16.0465
Tennessee.................................................... 16.2034
Texas........................................................ 15.8229
Utah......................................................... 18.8636
Vermont...................................................... 19.9246
Virginia..................................................... 16.7397
Washington................................................... 22.1244
West Virginia................................................ 17.0883
Wisconsin.................................................... 18.5514
Wyoming...................................................... 18.7641
------------------------------------------------------------------------
\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 reclass. GAF reclass.
hospitals hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR................................... 0.9120 0.9389
Arecibo, PR..................................... 1.0334 1.0228
Caguas, PR...................................... 0.9789 0.9855 0.9789 0.9855
Mayaguez, PR.................................... 1.0033 1.0023
Ponce, PR....................................... 1.0669 1.0453
San Juan-Bayamon, PR............................ 0.9996 0.9997
Rural Puerto Rico............................... 0.9120 0.9389
----------------------------------------------------------------------------------------------------------------
Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean
Length of Stay
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic
weights mean LOS mean LOS
----------------------------------------------------------------------------------------------------------------
1.............. 01 SURG CRANIOTOMY AGE >17 EXCEPT 3.0957 6.5 9.3
FOR TRAUMA.
2.............. 01 SURG CRANIOTOMY FOR TRAUMA AGE 3.1047 7.4 9.9
>17.
3.............. 01 SURG *CRANIOTOMY AGE 0-17...... 1.9619 12.7 12.7
4.............. 01 SURG SPINAL PROCEDURES......... 2.3205 4.9 7.5
5.............. 01 SURG EXTRACRANIAL VASCULAR 1.4466 2.5 3.4
PROCEDURES.
6.............. 01 SURG CARPAL TUNNEL RELEASE..... .8119 2.2 3.1
7.............. 01 SURG PERIPH & CRANIAL NERVE & 2.4986 6.9 10.4
OTHER NERV SYST PROC W CC.
[[Page 41597]]
8.............. 01 SURG PERIPH & CRANIAL NERVE & 1.3426 2.2 3.1
OTHER NERV SYST PROC W/O
CC.
9.............. 01 MED SPINAL DISORDERS & 1.1917 4.6 6.3
INJURIES.
10............. 01 MED NERVOUS SYSTEM NEOPLASMS W 1.2036 4.9 6.6
CC.
11............. 01 MED NERVOUS SYSTEM NEOPLASMS W/ .8283 3.0 4.1
O CC.
12............. 01 MED DEGENERATIVE NERVOUS .8904 4.6 6.3
SYSTEM DISORDERS.
13............. 01 MED MULTIPLE SCLEROSIS & .7599 4.2 5.2
CEREBELLAR ATAXIA.
14............. 01 MED SPECIFIC CEREBROVASCULAR 1.1914 4.7 6.1
DISORDERS EXCEPT TIA.
15............. 01 MED TRANSIENT ISCHEMIC ATTACK .7397 3.0 3.7
& PRECEREBRAL OCCLUSIONS.
16............. 01 MED NONSPECIFIC 1.0985 4.6 5.9
CEREBROVASCULAR DISORDERS
W CC.
17............. 01 MED NONSPECIFIC .6399 2.6 3.4
CEREBROVASCULAR DISORDERS
W/O CC.
18............. 01 MED CRANIAL & PERIPHERAL NERVE .9353 4.2 5.5
DISORDERS W CC.
19............. 01 MED CRANIAL & PERIPHERAL NERVE .6503 3.0 3.8
DISORDERS W/O CC.
20............. 01 MED NERVOUS SYSTEM INFECTION 2.6125 7.7 10.2
EXCEPT VIRAL MENINGITIS.
21............. 01 MED VIRAL MENINGITIS.......... 1.5032 5.0 6.8
22............. 01 MED HYPERTENSIVE .9621 3.8 4.9
ENCEPHALOPATHY.
23............. 01 MED NONTRAUMATIC STUPOR & COMA .7746 3.1 4.2
24............. 01 MED SEIZURE & HEADACHE AGE >17 .9770 3.7 5.0
W CC.
25............. 01 MED SEIZURE & HEADACHE AGE >17 .5911 2.6 3.4
W/O CC.
26............. 01 MED SEIZURE & HEADACHE AGE 0- .6337 2.8 3.6
17.
27............. 01 MED TRAUMATIC STUPOR & COMA, 1.3581 3.3 5.3
COMA >1 HR.
28............. 01 MED TRAUMATIC STUPOR & COMA, 1.2690 4.5 6.2
COMA <1 HR AGE >17 W CC.
29............. 01 MED TRAUMATIC STUPOR & COMA, .6859 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... .8497 3.2 4.3
32............. 01 MED CONCUSSION AGE >17 W/O CC. .5295 2.1 2.7
33............. 01 MED *CONCUSSION AGE 0-17...... .2085 1.6 1.6
34............. 01 MED OTHER DISORDERS OF NERVOUS 1.0275 3.9 5.3
SYSTEM W CC.
35............. 01 MED OTHER DISORDERS OF NERVOUS .5937 2.7 3.5
SYSTEM W/O CC.
36............. 02 SURG RETINAL PROCEDURES........ .6834 1.2 1.4
37............. 02 SURG ORBITAL PROCEDURES........ 1.0318 2.6 3.8
38............. 02 SURG PRIMARY IRIS PROCEDURES... .4875 1.9 2.6
39............. 02 SURG LENS PROCEDURES WITH OR .5704 1.4 1.9
WITHOUT VITRECTOMY.
40............. 02 SURG EXTRAOCULAR PROCEDURES .8170 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 .6236 1.6 2.1
EXCEPT RETINA, IRIS &
LENS.
43............. 02 MED HYPHEMA................... .4515 2.6 4.1
44............. 02 MED ACUTE MAJOR EYE INFECTIONS .6496 4.1 5.0
45............. 02 MED NEUROLOGICAL EYE DISORDERS .6941 2.7 3.4
46............. 02 MED OTHER DISORDERS OF THE EYE .7525 3.5 4.6
AGE >17 W CC.
47............. 02 MED OTHER DISORDERS OF THE EYE .4784 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 1.8557 3.7 5.0
PROCEDURES.
50............. 03 SURG SIALOADENECTOMY........... .8401 1.6 2.0
51............. 03 SURG SALIVARY GLAND PROCEDURES .8504 1.9 2.9
EXCEPT SIALOADENECTOMY.
52............. 03 SURG CLEFT LIP & PALATE REPAIR. .7696 1.5 1.9
53............. 03 SURG SINUS & MASTOID PROCEDURES 1.1784 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, .8686 1.9 2.9
MOUTH & THROAT PROCEDURES.
56............. 03 SURG RHINOPLASTY............... .8893 2.1 2.8
57............. 03 SURG T&A PROC, EXCEPT 1.1589 2.8 4.5
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 .6720 1.9 2.5
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 1.2597 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 & 1.3136 3.0 4.5
THROAT O.R. PROCEDURES.
64............. 03 MED EAR, NOSE, MOUTH & THROAT 1.2464 4.3 6.6
MALIGNANCY.
65............. 03 MED DYSEQUILIBRIUM............ .5261 2.3 2.9
66............. 03 MED EPISTAXIS................. .5548 2.6 3.2
67............. 03 MED EPIGLOTTITIS.............. .8031 2.9 3.7
68............. 03 MED OTITIS MEDIA & URI AGE >17 .6758 3.4 4.2
W CC.
69............. 03 MED OTITIS MEDIA & URI AGE >17 .5191 2.7 3.3
W/O CC.
70............. 03 MED OTITIS MEDIA & URI AGE 0- .3985 2.3 2.7
17.
71............. 03 MED LARYNGOTRACHEITIS......... .6136 2.7 3.4
72............. 03 MED NASAL TRAUMA & DEFORMITY.. .6462 2.6 3.4
73............. 03 MED OTHER EAR, NOSE, MOUTH & .7667 3.3 4.3
THROAT DIAGNOSES AGE >17.
[[Page 41598]]
74............. 03 MED * OTHER EAR, NOSE, MOUTH & .3356 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75............. 04 SURG MAJOR CHEST PROCEDURES.... 3.1107 7.8 9.9
76............. 04 SURG OTHER RESP SYSTEM O.R. 2.7208 8.3 11.1
PROCEDURES W CC.
77............. 04 SURG OTHER RESP SYSTEM O.R. 1.2113 3.6 5.0
PROCEDURES W/O CC.
78............. 04 MED PULMONARY EMBOLISM........ 1.3861 6.1 7.1
79............. 04 MED RESPIRATORY INFECTIONS & 1.6439 6.6 8.4
INFLAMMATIONS AGE >17 W
CC.
80............. 04 MED RESPIRATORY INFECTIONS & .8980 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..... 1.3656 5.2 7.0
83............. 04 MED MAJOR CHEST TRAUMA W CC... .9796 4.3 5.5
84............. 04 MED MAJOR CHEST TRAUMA W/O CC. .5278 2.6 3.2
85............. 04 MED PLEURAL EFFUSION W CC..... 1.2421 5.0 6.5
86............. 04 MED PLEURAL EFFUSION W/O CC... .6724 2.9 3.8
87............. 04 MED PULMONARY EDEMA & 1.3694 4.8 6.3
RESPIRATORY FAILURE.
88............. 04 MED CHRONIC OBSTRUCTIVE .9406 4.3 5.3
PULMONARY DISEASE.
89............. 04 MED SIMPLE PNEUMONIA & 1.0855 5.1 6.1
PLEURISY AGE >17 W CC.
90............. 04 MED SIMPLE PNEUMONIA & .6734 3.7 4.3
PLEURISY AGE >17 W/O CC.
91............. 04 MED SIMPLE PNEUMONIA & .6334 3.3 4.0
PLEURISY AGE 0-17.
92............. 04 MED INTERSTITIAL LUNG DISEASE 1.1786 5.0 6.3
W CC.
93............. 04 MED INTERSTITIAL LUNG DISEASE .7644 3.5 4.3
W/O CC.
94............. 04 MED PNEUMOTHORAX W CC......... 1.1910 4.8 6.4
95............. 04 MED PNEUMOTHORAX W/O CC....... .5944 2.9 3.6
96............. 04 MED BRONCHITIS & ASTHMA AGE .7943 3.9 4.8
>17 W CC.
97............. 04 MED BRONCHITIS & ASTHMA AGE .5954 3.1 3.7
>17 W/O CC.
98............. 04 MED BRONCHITIS & ASTHMA AGE 0- .6859 3.3 4.5
17.
99............. 04 MED RESPIRATORY SIGNS & .6817 2.4 3.1
SYMPTOMS W CC.
100............ 04 MED RESPIRATORY SIGNS & .5268 1.8 2.2
SYMPTOMS W/O CC.
101............ 04 MED OTHER RESPIRATORY SYSTEM .8490 3.3 4.4
DIAGNOSES W CC.
102............ 04 MED OTHER RESPIRATORY SYSTEM .5349 2.1 2.7
DIAGNOSES W/O CC.
103............ 05 SURG HEART TRANSPLANT.......... 19.5100 35.7 56.5
104............ 05 SURG CARDIAC VALVE & OTHER 7.2361 9.3 11.9
MAJOR CARDIOTHORACIC PROC
W CARDIAC CATH.
105............ 05 SURG CARDIAC VALVE & OTHER 5.6607 7.6 9.4
MAJOR CARDIOTHORACIC PROC
W/O CARDIAC CATH.
106............ 05 SURG CORONARY BYPASS W PTCA.... 7.3334 9.1 10.9
107............ 05 SURG CORONARY BYPASS W CARDIAC 5.4639 9.3 10.5
CATH.
108............ 05 SURG OTHER CARDIOTHORACIC 5.7715 8.3 11.0
PROCEDURES.
109............ 05 SURG CORONARY BYPASS W/O PTCA 4.0403 6.9 7.8
OR CARDIAC CATH.
110............ 05 SURG MAJOR CARDIOVASCULAR 4.1600 7.2 9.6
PROCEDURES W CC.
111............ 05 SURG MAJOR CARDIOVASCULAR 2.2267 4.9 5.7
PROCEDURES W/O CC.
112............ 05 SURG PERCUTANEOUS 1.9222 2.7 3.8
CARDIOVASCULAR PROCEDURES.
113............ 05 SURG AMPUTATION FOR CIRC SYSTEM 2.7283 9.5 12.6
DISORDERS EXCEPT UPPER
LIMB & TOE.
114............ 05 SURG UPPER LIMB & TOE 1.5555 6.0 8.2
AMPUTATION FOR CIRC
SYSTEM DISORDERS.
115............ 05 SURG PRM CARD PACEM IMPL W AMI, 3.4727 6.2 8.4
HRT FAIL OR SHK, OR AICD
LEAD OR GNRTR PR.
116............ 05 SURG OTH PERM CARD PACEMAK IMPL 2.4651 2.8 3.9
OR PTCA W CORONARY ARTERY
STENT IMPLNT.
117............ 05 SURG CARDIAC PACEMAKER REVISION 1.2931 2.7 4.1
EXCEPT DEVICE REPLACEMENT.
118............ 05 SURG CARDIAC PACEMAKER DEVICE 1.5480 2.0 2.9
REPLACEMENT.
119............ 05 SURG VEIN LIGATION & STRIPPING. 1.2297 3.0 4.9
120............ 05 SURG OTHER CIRCULATORY SYSTEM 2.0136 5.0 8.2
O.R. PROCEDURES.
121............ 05 MED CIRCULATORY DISORDERS W 1.6295 5.6 6.8
AMI & MAJOR COMP,
DISCHARGED ALIVE.
122............ 05 MED CIRCULATORY DISORDERS W 1.1063 3.4 4.2
AMI W/O MAJOR COMP,
DISCHARGED ALIVE.
123............ 05 MED CIRCULATORY DISORDERS W 1.5108 2.7 4.4
AMI, EXPIRED.
124............ 05 MED CIRCULATORY DISORDERS 1.4020 3.4 4.5
EXCEPT AMI, W CARD CATH &
COMPLEX DIAG.
125............ 05 MED CIRCULATORY DISORDERS 1.0436 2.2 2.8
EXCEPT AMI, W CARD CATH W/
O COMPLEX DIAG.
126............ 05 MED ACUTE & SUBACUTE 2.5170 9.3 12.1
ENDOCARDITIS.
127............ 05 MED HEART FAILURE & SHOCK..... 1.0144 4.2 5.4
128............ 05 MED DEEP VEIN THROMBOPHLEBITIS .7645 5.1 5.9
129............ 05 MED CARDIAC ARREST, 1.0770 1.8 2.8
UNEXPLAINED.
130............ 05 MED PERIPHERAL VASCULAR .9469 4.7 5.9
DISORDERS W CC.
[[Page 41599]]
131............ 05 MED PERIPHERAL VASCULAR .6050 3.7 4.5
DISORDERS W/O CC.
132............ 05 MED ATHEROSCLEROSIS W CC...... .6713 2.5 3.1
133............ 05 MED ATHEROSCLEROSIS W/O CC.... .5675 1.9 2.4
134............ 05 MED HYPERTENSION.............. .5846 2.6 3.3
135............ 05 MED CARDIAC CONGENITAL & .8704 3.3 4.4
VALVULAR DISORDERS AGE
17 W CC.
136............ 05 MED CARDIAC CONGENITAL & .6004 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 & .8154 3.1 4.0
CONDUCTION DISORDERS W CC.
139............ 05 MED CARDIAC ARRHYTHMIA & .5079 2.1 2.5
CONDUCTION DISORDERS W/O
CC.
140............ 05 MED ANGINA PECTORIS........... .5829 2.3 2.8
141............ 05 MED SYNCOPE & COLLAPSE W CC... .7091 2.9 3.7
142............ 05 MED SYNCOPE & COLLAPSE W/O CC. .5419 2.2 2.7
143............ 05 MED CHEST PAIN................ .5342 1.8 2.2
144............ 05 MED OTHER CIRCULATORY SYSTEM 1.1526 3.8 5.4
DIAGNOSES W CC.
145............ 05 MED OTHER CIRCULATORY SYSTEM .6497 2.2 2.8
DIAGNOSES W/O CC.
146............ 06 SURG RECTAL RESECTION W CC..... 2.7862 9.1 10.3
147............ 06 SURG RECTAL RESECTION W/O CC... 1.6382 6.1 6.7
148............ 06 SURG MAJOR SMALL & LARGE BOWEL 3.4289 10.1 12.1
PROCEDURES W CC.
149............ 06 SURG MAJOR SMALL & LARGE BOWEL 1.5723 6.2 6.7
PROCEDURES W/O CC.
150............ 06 SURG PERITONEAL ADHESIOLYSIS W 2.8098 9.0 11.0
CC.
151............ 06 SURG PERITONEAL ADHESIOLYSIS W/ 1.3437 4.9 6.0
O CC.
152............ 06 SURG MINOR SMALL & LARGE BOWEL 1.9606 6.9 8.3
PROCEDURES W CC.
153............ 06 SURG MINOR SMALL & LARGE BOWEL 1.2170 5.0 5.6
PROCEDURES W/O CC.
154............ 06 SURG STOMACH, ESOPHAGEAL & 4.1335 10.1 13.2
DUODENAL PROCEDURES AGE
>17 W CC.
155............ 06 SURG STOMACH, ESOPHAGEAL & 1.3781 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 1.2392 4.0 5.6
CC.
158............ 06 SURG ANAL & STOMAL PROCEDURES W/ .6561 2.1 2.6
O CC.
159............ 06 SURG HERNIA PROCEDURES EXCEPT 1.3097 3.7 5.0
INGUINAL & FEMORAL AGE
>17 W CC.
160............ 06 SURG HERNIA PROCEDURES EXCEPT .7801 2.2 2.7
INGUINAL & FEMORAL AGE
>17 W/O CC.
161............ 06 SURG INGUINAL & FEMORAL HERNIA 1.0976 2.9 4.2
PROCEDURES AGE >17 W CC.
162............ 06 SURG INGUINAL & FEMORAL HERNIA .6283 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 2.3463 7.3 8.5
PRINCIPAL DIAG W CC.
165............ 06 SURG APPENDECTOMY W COMPLICATED 1.2655 4.4 4.9
PRINCIPAL DIAG W/O CC.
166............ 06 SURG APPENDECTOMY W/O 1.4788 4.1 5.1
COMPLICATED PRINCIPAL
DIAG W CC.
167............ 06 SURG APPENDECTOMY W/O .8995 2.4 2.8
COMPLICATED PRINCIPAL
DIAG W/O CC.
168............ 03 SURG MOUTH PROCEDURES W CC..... 1.2039 3.3 4.6
169............ 03 SURG MOUTH PROCEDURES W/O CC... .7492 1.9 2.5
170............ 06 SURG OTHER DIGESTIVE SYSTEM 2.8435 7.8 11.3
O.R. PROCEDURES W CC.
171............ 06 SURG OTHER DIGESTIVE SYSTEM 1.2556 3.6 4.8
O.R. PROCEDURES W/O CC.
172............ 06 MED DIGESTIVE MALIGNANCY W CC. 1.3144 5.1 6.9
173............ 06 MED DIGESTIVE MALIGNANCY W/O .7123 2.7 3.8
CC.
174............ 06 MED G.I. HEMORRHAGE W CC...... .9981 3.9 4.9
175............ 06 MED G.I. HEMORRHAGE W/O CC.... .5456 2.5 2.9
176............ 06 MED COMPLICATED PEPTIC ULCER.. 1.0968 4.1 5.3
177............ 06 MED UNCOMPLICATED PEPTIC ULCER .8802 3.7 4.5
W CC.
178............ 06 MED UNCOMPLICATED PEPTIC ULCER .6502 2.6 3.2
W/O CC.
179............ 06 MED INFLAMMATORY BOWEL DISEASE 1.0869 4.8 6.2
180............ 06 MED G.I. OBSTRUCTION W CC..... .9206 4.2 5.4
181............ 06 MED G.I. OBSTRUCTION W/O CC... .5277 2.8 3.4
182............ 06 MED ESOPHAGITIS, GASTROENT & .7821 3.4 4.3
MISC DIGEST. DISORDERS
AGE >17 W CC.
183............ 06 MED ESOPHAGITIS, GASTROENT & .5710 2.4 3.0
MISC DIGEST. DISORDERS
AGE >17 W/O CC.
184............ 06 MED ESOPHAGITIS, GASTROENT & .5286 2.3 3.0
MISC DIGEST. DISORDERS
AGE 0-17.
185............ 03 MED DENTAL & ORAL DIS EXCEPT .8593 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 & .7790 2.9 3.9
RESTORATIONS.
188............ 06 MED OTHER DIGESTIVE SYSTEM 1.0942 4.1 5.6
DIAGNOSES AGE >17 W CC.
[[Page 41600]]
189............ 06 MED OTHER DIGESTIVE SYSTEM .5831 2.4 3.2
DIAGNOSES AGE >17 W/O CC.
190............ 06 MED OTHER DIGESTIVE SYSTEM 1.0011 3.9 5.6
DIAGNOSES AGE 0-17.
191............ 07 SURG PANCREAS, LIVER & SHUNT 4.3837 10.6 14.2
PROCEDURES W CC.
192............ 07 SURG PANCREAS, LIVER & SHUNT 1.8454 5.7 7.0
PROCEDURES W/O CC.
193............ 07 SURG BILIARY TRACT PROC EXCEPT 3.4161 10.3 12.6
ONLY CHOLECYST W OR W/O
C.D.E. W CC.
194............ 07 SURG BILIARY TRACT PROC EXCEPT 1.6401 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 2.9359 8.4 10.0
CC.
196............ 07 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6554 4.9 5.7
O CC.
197............ 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.4183 7.1 8.6
LAPAROSCOPE W/O C.D.E. W
CC.
198............ 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.2324 3.9 4.5
LAPAROSCOPE W/O C.D.E. W/
O CC.
199............ 07 SURG HEPATOBILIARY DIAGNOSTIC 2.3317 7.1 9.6
PROCEDURE FOR MALIGNANCY.
200............ 07 SURG HEPATOBILIARY DIAGNOSTIC 3.0708 7.2 11.1
PROCEDURE FOR NON-
MALIGNANCY.
201............ 07 SURG OTHER HEPATOBILIARY OR 3.5838 10.3 14.1
PANCREAS O.R. PROCEDURES.
202............ 07 MED CIRRHOSIS & ALCOHOLIC 1.3188 5.0 6.6
HEPATITIS.
203............ 07 MED MALIGNANCY OF 1.3046 5.0 6.7
HEPATOBILIARY SYSTEM OR
PANCREAS.
204............ 07 MED DISORDERS OF PANCREAS 1.2161 4.6 6.0
EXCEPT MALIGNANCY.
205............ 07 MED DISORDERS OF LIVER EXCEPT 1.1816 4.7 6.4
MALIG, CIRR, ALC HEPA W
CC.
206............ 07 MED DISORDERS OF LIVER EXCEPT .7163 3.1 4.1
MALIG, CIRR, ALC HEPA W/O
CC.
207............ 07 MED DISORDERS OF THE BILIARY 1.1013 4.0 5.2
TRACT W CC.
208............ 07 MED DISORDERS OF THE BILIARY .6455 2.3 2.9
TRACT W/O CC.
209............ 08 SURG MAJOR JOINT & LIMB 2.1175 4.6 5.2
REATTACHMENT PROCEDURES
OF LOWER EXTREMITY.
210............ 08 SURG HIP & FEMUR PROCEDURES 1.8028 5.9 6.8
EXCEPT MAJOR JOINT AGE
>17 W CC.
211............ 08 SURG HIP & FEMUR PROCEDURES 1.2609 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 1.7130 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 2.1400 6.9 9.6
MUSCULOSKELETAL SYSTEM &
CONNECTIVE TISSUE.
217............ 08 SURG WND DEBRID & SKN GRFT 2.8006 8.6 12.6
EXCEPT HAND, FOR
MUSCSKELET & CONN TISS
DIS.
218............ 08 SURG LOWER EXTREM & HUMER PROC 1.4900 4.2 5.3
EXCEPT HIP, FOOT, FEMUR
AGE >17 W CC.
219............ 08 SURG LOWER EXTREM & HUMER PROC 1.0117 2.7 3.2
EXCEPT HIP, FOOT, FEMUR
AGE >17 W/O CC.
220............ 08 SURG * LOWER EXTREM & HUMER .5841 5.3 5.3
PROC 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, .9378 2.0 2.6
OR OTHER UPPER EXTREMITY
PROC W CC.
224............ 08 SURG SHOULDER, ELBOW OR FOREARM .8042 1.7 2.0
PROC, EXC MAJOR JOINT
PROC, W/O CC.
225............ 08 SURG FOOT PROCEDURES........... 1.0518 3.2 4.5
226............ 08 SURG SOFT TISSUE PROCEDURES W 1.4383 4.1 6.0
CC.
227............ 08 SURG SOFT TISSUE PROCEDURES W/O .8181 2.1 2.8
CC.
228............ 08 SURG MAJOR THUMB OR JOINT PROC, 1.0516 2.4 3.6
OR OTH HAND OR WRIST PROC
W CC.
229............ 08 SURG HAND OR WRIST PROC, EXCEPT .7348 1.9 2.4
MAJOR JOINT PROC, W/O CC.
230............ 08 SURG LOCAL EXCISION & REMOVAL 1.1722 3.2 4.8
OF INT FIX DEVICES OF HIP
& FEMUR.
231............ 08 SURG LOCAL EXCISION & REMOVAL 1.3623 3.1 4.6
OF INT FIX DEVICES EXCEPT
HIP & FEMUR.
232............ 08 SURG ARTHROSCOPY............... 1.1567 2.4 4.1
233............ 08 SURG OTHER MUSCULOSKELET SYS & 2.0424 5.3 7.5
CONN TISS O.R. PROC W CC.
234............ 08 SURG OTHER MUSCULOSKELET SYS & 1.2450 2.7 3.5
CONN TISS O.R. PROC W/O
CC.
235............ 08 MED FRACTURES OF FEMUR........ .7479 3.8 5.1
236............ 08 MED FRACTURES OF HIP & PELVIS. .7157 3.9 5.0
237............ 08 MED SPRAINS, STRAINS, & .5451 2.9 3.6
DISLOCATIONS OF HIP,
PELVIS & THIGH.
[[Page 41601]]
238............ 08 MED OSTEOMYELITIS............. 1.2831 6.4 8.4
239............ 08 MED PATHOLOGICAL FRACTURES & .9660 4.9 6.3
MUSCULOSKELETAL & CONN
TISS MALIGNANCY.
240............ 08 MED CONNECTIVE TISSUE 1.2328 5.0 6.7
DISORDERS W CC.
241............ 08 MED CONNECTIVE TISSUE .6089 3.2 4.0
DISORDERS W/O CC.
242............ 08 MED SEPTIC ARTHRITIS.......... 1.0168 5.1 6.7
243............ 08 MED MEDICAL BACK PROBLEMS..... .7164 3.7 4.7
244............ 08 MED BONE DISEASES & SPECIFIC .7024 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 .5545 3.0 3.7
247............ 08 MED SIGNS & SYMPTOMS OF .5563 2.6 3.4
MUSCULOSKELETAL SYSTEM &
CONN TISSUE.
248............ 08 MED TENDONITIS, MYOSITIS & .7554 3.6 4.6
BURSITIS.
249............ 08 MED AFTERCARE, MUSCULOSKELETAL .6504 2.5 3.5
SYSTEM & CONNECTIVE
TISSUE.
250............ 08 MED FX, SPRN, STRN & DISL OF .6700 3.2 4.1
FOREARM, HAND, FOOT AGE
>17 W CC.
251............ 08 MED FX, SPRN, STRN & DISL OF .4608 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 .7261 3.7 4.8
UPARM, LOWLEG EX FOOT AGE
>17 W CC.
254............ 08 MED FX, SPRN, STRN & DISL OF .4339 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 .7687 3.8 5.1
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES.
257............ 09 SURG TOTAL MASTECTOMY FOR .9134 2.3 2.9
MALIGNANCY W CC.
258............ 09 SURG TOTAL MASTECTOMY FOR .7227 1.8 2.1
MALIGNANCY W/O CC.
259............ 09 SURG SUBTOTAL MASTECTOMY FOR .8673 1.9 2.8
MALIGNANCY W CC.
260............ 09 SURG SUBTOTAL MASTECTOMY FOR .6444 1.3 1.5
MALIGNANCY W/O CC.
261............ 09 SURG BREAST PROC FOR NON- .9188 1.7 2.2
MALIGNANCY EXCEPT BIOPSY
& LOCAL EXCISION.
262............ 09 SURG BREAST BIOPSY & LOCAL .8392 2.7 3.9
EXCISION FOR NON-
MALIGNANCY.
263............ 09 SURG SKIN GRAFT &/OR DEBRID FOR 2.0609 8.7 11.8
SKN ULCER OR CELLULITIS W
CC.
264............ 09 SURG SKIN GRAFT &/OR DEBRID FOR 1.1216 5.3 7.1
SKN ULCER OR CELLULITIS W/
O CC.
265............ 09 SURG SKIN GRAFT &/OR DEBRID 1.5650 4.4 7.0
EXCEPT FOR SKIN ULCER OR
CELLULITIS W CC.
266............ 09 SURG SKIN GRAFT &/OR DEBRID .8495 2.4 3.3
EXCEPT FOR SKIN ULCER OR
CELLULITIS W/O CC.
267............ 09 SURG PERIANAL & PILONIDAL .9815 2.9 4.1
PROCEDURES.
268............ 09 SURG SKIN, SUBCUTANEOUS TISSUE 1.1979 2.4 3.8
& BREAST PLASTIC
PROCEDURES.
269............ 09 SURG OTHER SKIN, SUBCUT TISS & 1.6147 5.6 7.9
BREAST PROC W CC.
270............ 09 SURG OTHER SKIN, SUBCUT TISS & .7447 2.2 3.1
BREAST PROC W/O CC.
271............ 09 MED SKIN ULCERS............... .9905 5.6 7.1
272............ 09 MED MAJOR SKIN DISORDERS W CC. 1.0003 4.8 6.3
273............ 09 MED MAJOR SKIN DISORDERS W/O .6275 3.3 4.4
CC.
274............ 09 MED MALIGNANT BREAST DISORDERS 1.1335 4.7 6.6
W CC.
275............ 09 MED MALIGNANT BREAST DISORDERS .6322 2.6 3.9
W/O CC.
276............ 09 MED NON-MALIGANT BREAST .6529 3.5 4.4
DISORDERS.
277............ 09 MED CELLULITIS AGE >17 W CC... .8312 4.7 5.8
278............ 09 MED CELLULITIS AGE >17 W/O CC. .5621 3.7 4.4
279............ 09 MED CELLULITIS AGE 0-17....... .6641 4.1 5.1
280............ 09 MED TRAUMA TO THE SKIN, SUBCUT .6736 3.3 4.2
TISS & BREAST AGE >17 W
CC.
281............ 09 MED TRAUMA TO THE SKIN, SUBCUT .4596 2.4 3.1
TISS & BREAST AGE >17 W/O
CC.
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. .7129 3.6 4.7
284............ 09 MED MINOR SKIN DISORDERS W/O .4373 2.5 3.2
CC.
285............ 10 SURG AMPUTAT OF LOWER LIMB FOR 2.0217 7.7 10.6
ENDOCRINE, NUTRIT, &
METABOL DISORDERS.
286............ 10 SURG ADRENAL & PITUITARY 2.2287 5.2 6.6
PROCEDURES.
287............ 10 SURG SKIN GRAFTS & WOUND DEBRID 1.8045 7.4 10.4
FOR ENDOC, NUTRIT & METAB
DISORDERS.
288............ 10 SURG O.R. PROCEDURES FOR 2.0665 4.6 5.7
OBESITY.
289............ 10 SURG PARATHYROID PROCEDURES.... .9756 2.1 3.0
[[Page 41602]]
290............ 10 SURG THYROID PROCEDURES........ .9174 1.9 2.4
291............ 10 SURG THYROGLOSSAL PROCEDURES... .6732 1.6 2.0
292............ 10 SURG OTHER ENDOCRINE, NUTRIT & 2.4719 7.1 10.4
METAB O.R. PROC W CC.
293............ 10 SURG OTHER ENDOCRINE, NUTRIT & 1.1942 3.5 5.0
METAB O.R. PROC W/O CC.
294............ 10 MED DIABETES AGE >35.......... .7518 3.7 4.7
295............ 10 MED DIABETES AGE 0-35......... .7464 3.0 3.9
296............ 10 MED NUTRITIONAL & MISC .8556 4.0 5.3
METABOLIC DISORDERS AGE
>17 W CC.
297............ 10 MED NUTRITIONAL & MISC .5204 2.8 3.5
METABOLIC DISORDERS AGE
>17 W/O CC.
298............ 10 MED NUTRITIONAL & MISC .4954 2.4 3.5
METABOLIC DISORDERS AGE 0-
17.
299............ 10 MED INBORN ERRORS OF .9475 3.8 5.4
METABOLISM.
300............ 10 MED ENDOCRINE DISORDERS W CC.. 1.0779 4.8 6.2
301............ 10 MED ENDOCRINE DISORDERS W/O CC .5889 2.8 3.6
302............ 11 SURG KIDNEY TRANSPLANT......... 3.5669 8.2 9.7
303............ 11 SURG KIDNEY, URETER & MAJOR 2.5401 7.2 8.8
BLADDER PROCEDURES FOR
NEOPLASM.
304............ 11 SURG KIDNEY, URETER & MAJOR 2.3458 6.5 8.9
BLADDER PROC FOR NON-
NEOPL W CC.
305............ 11 SURG KIDNEY, URETER & MAJOR 1.1857 3.2 3.9
BLADDER PROC FOR NON-
NEOPL W/O CC.
306............ 11 SURG PROSTATECTOMY W CC........ 1.2448 3.7 5.4
307............ 11 SURG PROSTATECTOMY W/O CC...... .6588 2.0 2.4
308............ 11 SURG MINOR BLADDER PROCEDURES W 1.5907 4.1 6.1
CC.
309............ 11 SURG MINOR BLADDER PROCEDURES W/ .9442 2.0 2.5
O CC.
310............ 11 SURG TRANSURETHRAL PROCEDURES W 1.0869 3.0 4.3
CC.
311............ 11 SURG TRANSURETHRAL PROCEDURES W/ .6126 1.6 1.9
O CC.
312............ 11 SURG URETHRAL PROCEDURES, AGE 1.0270 3.1 4.6
>17 W CC.
313............ 11 SURG URETHRAL PROCEDURES, AGE .6640 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 2.0660 4.5 7.8
TRACT O.R. PROCEDURES.
316............ 11 MED RENAL FAILURE............. 1.3380 4.9 6.7
317............ 11 MED ADMIT FOR RENAL DIALYSIS.. .6965 2.1 3.2
318............ 11 MED KIDNEY & URINARY TRACT 1.1413 4.4 6.0
NEOPLASMS W CC.
319............ 11 MED KIDNEY & URINARY TRACT .6187 2.1 2.9
NEOPLASMS W/O CC.
320............ 11 MED KIDNEY & URINARY TRACT .8647 4.4 5.4
INFECTIONS AGE >17 W CC.
321............ 11 MED KIDNEY & URINARY TRACT .5785 3.3 3.9
INFECTIONS AGE >17 W/O CC.
322............ 11 MED KIDNEY & URINARY TRACT .5606 3.0 3.7
INFECTIONS AGE 0-17.
323............ 11 MED URINARY STONES W CC, &/OR .7816 2.4 3.2
ESW LITHOTRIPSY.
324............ 11 MED URINARY STONES W/O CC..... .4475 1.6 1.9
325............ 11 MED KIDNEY & URINARY TRACT .6287 3.0 3.9
SIGNS & SYMPTOMS AGE >17
W CC.
326............ 11 MED KIDNEY & URINARY TRACT .4203 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 .7024 2.7 3.7
W CC.
329............ 11 MED URETHRAL STRICTURE AGE >17 .5172 1.7 2.4
W/O CC.
330............ 11 MED * URETHRAL STRICTURE AGE 0- .3189 1.6 1.6
17.
331............ 11 MED OTHER KIDNEY & URINARY 1.0157 4.1 5.5
TRACT DIAGNOSES AGE >17 W
CC.
332............ 11 MED OTHER KIDNEY & URINARY .6104 2.6 3.4
TRACT DIAGNOSES AGE >17 W/
O CC.
333............ 11 MED OTHER KIDNEY & URINARY .7642 3.3 4.4
TRACT DIAGNOSES AGE 0-17.
334............ 12 SURG MAJOR MALE PELVIC 1.5864 4.3 5.0
PROCEDURES W CC.
335............ 12 SURG MAJOR MALE PELVIC 1.1911 3.3 3.5
PROCEDURES W/O CC.
336............ 12 SURG TRANSURETHRAL .8965 2.8 3.6
PROSTATECTOMY W CC.
337............ 12 SURG TRANSURETHRAL .6229 2.0 2.2
PROSTATECTOMY W/O CC.
338............ 12 SURG TESTES PROCEDURES, FOR 1.1552 3.3 5.1
MALIGNANCY.
339............ 12 SURG TESTES PROCEDURES, NON- 1.0600 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.......... 1.1141 2.1 3.2
342............ 12 SURG CIRCUMCISION AGE >17...... .8601 2.6 3.5
343............ 12 SURG * CIRCUMCISION AGE 0-17... .1540 1.7 1.7
344............ 12 SURG OTHER MALE REPRODUCTIVE 1.1025 1.6 2.4
SYSTEM O.R. PROCEDURES
FOR MALIGNANCY.
345............ 12 SURG OTHER MALE REPRODUCTIVE .8816 2.5 3.7
SYSTEM O.R. PROC EXCEPT
FOR MALIGNANCY.
346............ 12 MED MALIGNANCY, MALE .9645 4.2 5.7
REPRODUCTIVE SYSTEM, W CC.
347............ 12 MED MALIGNANCY, MALE .5828 2.3 3.1
REPRODUCTIVE SYSTEM, W/O
CC.
348............ 12 MED BENIGN PROSTATIC .6983 3.2 4.2
HYPERTROPHY W CC.
349............ 12 MED BENIGN PROSTATIC .4345 2.0 2.5
HYPERTROPHY W/O CC.
350............ 12 MED INFLAMMATION OF THE MALE .6957 3.6 4.4
REPRODUCTIVE SYSTEM.
[[Page 41603]]
351............ 12 MED * STERILIZATION, MALE..... .2363 1.3 1.3
352............ 12 MED OTHER MALE REPRODUCTIVE .6769 2.7 3.9
SYSTEM DIAGNOSES.
353............ 13 SURG PELVIC EVISCERATION, 1.9721 5.4 7.1
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354............ 13 SURG UTERINE,ADNEXA PROC FOR 1.5134 4.8 5.8
NON-OVARIAN/ADNEXAL MALIG
W CC.
355............ 13 SURG UTERINE,ADNEXA PROC FOR .9477 3.2 3.4
NON-OVARIAN/ADNEXAL MALIG
W/O CC.
356............ 13 SURG FEMALE REPRODUCTIVE SYSTEM .7916 2.2 2.6
RECONSTRUCTIVE PROCEDURES.
357............ 13 SURG UTERINE & ADNEXA PROC FOR 2.3699 7.0 8.7
OVARIAN OR ADNEXAL
MALIGNANCY.
358............ 13 SURG UTERINE & ADNEXA PROC FOR 1.2357 3.7 4.4
NON-MALIGNANCY W CC.
359............ 13 SURG UTERINE & ADNEXA PROC FOR .8699 2.7 2.9
NON-MALIGNANCY W/O CC.
360............ 13 SURG VAGINA, CERVIX & VULVA .8823 2.5 3.0
PROCEDURES.
361............ 13 SURG LAPAROSCOPY & INCISIONAL 1.1894 2.4 3.4
TUBAL INTERRUPTION.
362............ 13 SURG * ENDOSCOPIC TUBAL .3020 1.4 1.4
INTERRUPTION.
363............ 13 SURG D&C, CONIZATION & RADIO- .7807 2.5 3.3
IMPLANT, FOR MALIGNANCY.
364............ 13 SURG D&C, CONIZATION EXCEPT FOR .7601 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 1.2474 4.7 6.8
REPRODUCTIVE SYSTEM W CC.
367............ 13 MED MALIGNANCY, FEMALE .5509 2.2 3.0
REPRODUCTIVE SYSTEM W/O
CC.
368............ 13 MED INFECTIONS, FEMALE 1.0499 4.8 6.2
REPRODUCTIVE SYSTEM.
369............ 13 MED MENSTRUAL & OTHER FEMALE .5526 2.4 3.2
REPRODUCTIVE SYSTEM
DISORDERS.
370............ 14 SURG CESAREAN SECTION W CC..... 1.0974 4.4 5.9
371............ 14 SURG CESAREAN SECTION W/O CC... .7212 3.3 3.6
372............ 14 MED VAGINAL DELIVERY W .5920 2.6 3.5
COMPLICATING DIAGNOSES.
373............ 14 MED VAGINAL DELIVERY W/O .4020 1.9 2.1
COMPLICATING DIAGNOSES.
374............ 14 SURG VAGINAL DELIVERY W .7081 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 .5342 2.4 3.4
DIAGNOSES W/O O.R.
PROCEDURE.
377............ 14 SURG POSTPARTUM & POST ABORTION 1.3506 3.1 5.4
DIAGNOSES W O.R.
PROCEDURE.
378............ 14 MED ECTOPIC PREGNANCY......... .9394 2.2 2.8
379............ 14 MED THREATENED ABORTION....... .4424 2.1 3.1
380............ 14 MED ABORTION W/O D&C.......... .3404 1.6 1.9
381............ 14 SURG ABORTION W D&C, ASPIRATION .6002 1.7 2.3
CURETTAGE OR HYSTEROTOMY.
382............ 14 MED FALSE LABOR............... .2045 1.2 1.3
383............ 14 MED OTHER ANTEPARTUM DIAGNOSES .5334 2.8 4.0
W MEDICAL COMPLICATIONS.
384............ 14 MED OTHER ANTEPARTUM DIAGNOSES .3437 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.
389............ 15 ................... * FULL TERM NEONATE W 1.8398 4.7 4.7
MAJOR 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....... 3.1411 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 1.6806 4.1 6.8
THE BLOOD AND BLOOD
FORMING ORGANS.
395............ 16 MED RED BLOOD CELL DISORDERS .8168 3.3 4.6
AGE >17.
396............ 16 MED RED BLOOD CELL DISORDERS 1.0917 2.1 3.2
AGE 0-17.
397............ 16 MED COAGULATION DISORDERS..... 1.2154 3.9 5.4
398............ 16 MED RETICULOENDOTHELIAL & 1.2507 4.7 6.0
IMMUNITY DISORDERS W CC.
399............ 16 MED RETICULOENDOTHELIAL & .7085 3.0 3.7
IMMUNITY DISORDERS W/O CC.
400............ 17 SURG LYMPHOMA & LEUKEMIA W 2.6610 5.9 9.1
MAJOR O.R. PROCEDURE.
401............ 17 SURG LYMPHOMA & NON-ACUTE 2.6191 7.8 11.1
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 1.7181 5.7 8.1
LEUKEMIA W CC.
404............ 17 MED LYMPHOMA & NON-ACUTE .8549 3.2 4.3
LEUKEMIA W/O CC.
[[Page 41604]]
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 2.7833 7.5 10.1
POORLY DIFF NEOPL W MAJ
O.R.PROC W CC.
407............ 17 SURG MYELOPROLIF DISORD OR 1.2463 3.4 4.2
POORLY DIFF NEOPL W MAJ
O.R.PROC W/O CC.
408............ 17 SURG MYELOPROLIF DISORD OR 1.9990 4.7 7.7
POORLY DIFF NEOPL W OTHER
O.R.PROC.
409............ 17 MED RADIOTHERAPY.............. 1.0631 4.5 6.1
410............ 17 MED CHEMOTHERAPY W/O ACUTE .9015 2.8 3.6
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411............ 17 MED HISTORY OF MALIGNANCY W/O .4335 1.9 2.4
ENDOSCOPY.
412............ 17 MED HISTORY OF MALIGNANCY W .4070 1.5 2.0
ENDOSCOPY.
413............ 17 MED OTHER MYELOPROLIF DIS OR 1.3925 5.5 7.5
POORLY DIFF NEOPL DIAG W
CC.
414............ 17 MED OTHER MYELOPROLIF DIS OR .7824 3.1 4.2
POORLY DIFF NEOPL DIAG W/
O CC.
415............ 18 SURG O.R. PROCEDURE FOR 3.5541 10.3 14.1
INFECTIOUS & PARASITIC
DISEASES.
416............ 18 MED SEPTICEMIA AGE >17........ 1.4988 5.6 7.3
417............ 18 MED SEPTICEMIA AGE 0-17....... .8695 3.5 4.8
418............ 18 MED POSTOPERATIVE & POST- .9931 4.8 6.1
TRAUMATIC INFECTIONS.
419............ 18 MED FEVER OF UNKNOWN ORIGIN .8885 3.9 4.9
AGE >17 W CC.
420............ 18 MED FEVER OF UNKNOWN ORIGIN .6136 3.0 3.7
AGE >17 W/O CC.
421............ 18 MED VIRAL ILLNESS AGE >17..... .6663 3.1 3.9
422............ 18 MED VIRAL ILLNESS & FEVER OF .4792 2.4 3.0
UNKNOWN ORIGIN AGE 0-17.
423............ 18 MED OTHER INFECTIOUS & 1.6019 5.7 7.7
PARASITIC DISEASES
DIAGNOSES.
424............ 19 SURG O.R. PROCEDURE W PRINCIPAL 2.3706 8.7 14.1
DIAGNOSES OF MENTAL
ILLNESS.
425............ 19 MED ACUTE ADJUSTMENT REACTION .6805 3.0 4.1
& PSYCHOLOGICAL
DYSFUNCTION.
426............ 19 MED DEPRESSIVE NEUROSES....... .5363 3.4 4.7
427............ 19 MED NEUROSES EXCEPT DEPRESSIVE .5714 3.4 4.9
428............ 19 MED DISORDERS OF PERSONALITY & .6982 4.4 6.9
IMPULSE CONTROL.
429............ 19 MED ORGANIC DISTURBANCES & .8448 4.9 6.7
MENTAL RETARDATION.
430............ 19 MED PSYCHOSES................. .7881 6.0 8.4
431............ 19 MED CHILDHOOD MENTAL DISORDERS .7532 4.7 7.1
432............ 19 MED OTHER MENTAL DISORDER .7083 3.3 5.2
DIAGNOSES.
433............ 20 ................... ALCOHOL/DRUG ABUSE OR .2961 2.3 3.1
DEPENDENCE, LEFT AMA.
434............ 20 ................... ALC/DRUG ABUSE OR DEPEND, .7296 3.9 5.2
DETOX OR OTH SYMPT TREAT
W CC.
435............ 20 ................... ALC/DRUG ABUSE OR DEPEND, .4275 3.4 4.4
DETOX OR OTH SYMPT TREAT
W/O CC.
436............ 20 ................... ALC/DRUG DEPENDENCE W .7850 10.7 13.6
REHABILITATION THERAPY.
437............ 20 ................... ALC/DRUG DEPENDENCE, .6864 7.5 9.0
COMBINED REHAB & DETOX
THERAPY.
438............ NO LONGER VALID........... .0000 .0 .0
439............ 21 SURG SKIN GRAFTS FOR INJURIES.. 1.6571 5.0 7.5
440............ 21 SURG WOUND DEBRIDEMENTS FOR 1.9354 5.7 9.0
INJURIES.
441............ 21 SURG HAND PROCEDURES FOR .9179 2.2 3.1
INJURIES.
442............ 21 SURG OTHER O.R. PROCEDURES FOR 2.2454 5.2 7.9
INJURIES W CC.
443............ 21 SURG OTHER O.R. PROCEDURES FOR .9614 2.5 3.3
INJURIES W/O CC.
444............ 21 MED TRAUMATIC INJURY AGE >17 W .7087 3.3 4.3
CC.
445............ 21 MED TRAUMATIC INJURY AGE >17 W/ .4800 2.4 3.0
O CC.
446............ 21 MED * TRAUMATIC INJURY AGE 0- .2962 2.4 2.4
17.
[[Page 41605]]
447............ 21 MED ALLERGIC REACTIONS AGE >17 .5220 1.9 2.5
448............ 21 MED * ALLERGIC REACTIONS AGE 0- .0974 2.9 2.9
17.
449............ 21 MED POISONING & TOXIC EFFECTS .8149 2.6 3.7
OF DRUGS AGE >17 W CC.
450............ 21 MED POISONING & TOXIC EFFECTS .4352 1.6 2.0
OF DRUGS AGE >17 W/O CC.
451............ 21 MED * POISONING & TOXIC .2631 2.1 2.1
EFFECTS OF DRUGS AGE 0-17.
452............ 21 MED COMPLICATIONS OF TREATMENT .9920 3.5 4.9
W CC.
453............ 21 MED COMPLICATIONS OF TREATMENT .5060 2.2 2.9
W/O CC.
454............ 21 MED OTHER INJURY, POISONING & .8152 3.2 4.5
TOXIC EFFECT DIAG W CC.
455............ 21 MED OTHER INJURY, POISONING & .4663 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 1.1309 2.4 4.5
OTHER CONTACT W HEALTH
SERVICES.
462............ 23 MED REHABILITATION............ 1.3599 9.9 12.4
463............ 23 MED SIGNS & SYMPTOMS W CC..... .6811 3.3 4.3
464............ 23 MED SIGNS & SYMPTOMS W/O CC... .4942 2.5 3.2
465............ 23 MED AFTERCARE W HISTORY OF .6720 2.0 3.6
MALIGNANCY AS SECONDARY
DIAGNOSIS.
466............ 23 MED AFTERCARE W/O HISTORY OF .7129 2.3 4.0
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467............ 23 MED OTHER FACTORS INFLUENCING .4986 2.1 3.3
HEALTH STATUS.
468............ EXTENSIVE O.R. PROCEDURE 3.6400 9.3 13.2
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 3.2205 4.9 5.6
MAJOR JOINT PROCS OF
LOWER EXTREMITY.
472............ NO LONGER VALID........... .0000 .0 .0
473............ 17 ACUTE LEUKEMIA W/O MAJOR 3.7200 7.8 13.4
O.R. PROCEDURE AGE >17.
474............ NO LONGER VALID........... .0000 .0 .0
475............ 04 MED RESPIRATORY SYSTEM 3.7065 8.0 11.2
DIAGNOSIS WITH VENTILATOR
SUPPORT.
476............ ....... SURG PROSTATIC O.R. PROCEDURE 2.2633 8.6 11.7
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477............ SURG NON-EXTENSIVE O.R. 1.7696 5.3 8.1
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478............ 05 SURG OTHER VASCULAR PROCEDURES 2.3515 5.0 7.3
W CC.
479............ 05 SURG OTHER VASCULAR PROCEDURES 1.4618 2.9 3.8
W/O CC.
480............ SURG LIVER 10.7834................... 17.5 23.1
TRANSPLANT
481............ SURG BONE MARROW TRANSPLANT.... 8.7285 21.9 24.9
482............ SURG TRACHEOSTOMY FOR FACE, 3.6454 9.9 12.9
MOUTH & NECK DIAGNOSES.
483............ SURG TRACHEOSTOMY EXCEPT FOR 16.1211 33.0 40.9
FACE, MOUTH & NECK
DIAGNOSES.
484............ 24 SURG CRANIOTOMY FOR MULTIPLE 5.5421 8.9 13.3
SIGNIFICANT TRAUMA.
485............ 24 SURG LIMB REATTACHMENT, HIP AND 3.0757 7.4 9.2
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TRA.
[[Page 41606]]
486............ 24 SURG OTHER O.R. PROCEDURES FOR 4.8962 8.4 12.3
MULTIPLE SIGNIFICANT
TRAUMA.
487............ 24 MED OTHER MULTIPLE SIGNIFICANT 1.9536 5.3 7.4
TRAUMA.
488............ 25 SURG HIV W EXTENSIVE O.R. 4.7891 12.0 18.1
PROCEDURE.
489............ 25 MED HIV W MAJOR RELATED 1.7913 6.1 8.8
CONDITION.
490............ 25 MED HIV W OR W/O OTHER RELATED .9651 3.8 5.3
CONDITION.
491............ 08 SURG MAJOR JOINT & LIMB 1.6673 3.0 3.5
REATTACHMENT PROCEDURES
OF UPPER EXTREMITY.
492............ 17 MED CHEMOTHERAPY W ACUTE 4.4470 11.4 16.8
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493............ 07 SURG LAPAROSCOPIC 1.8290 4.3 5.7
CHOLECYSTECTOMY W/O
C.D.E. W CC.
494............ 07 SURG LAPAROSCOPIC 1.0246 2.0 2.5
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
495............ SURG LUNG TRANSPLANT........... 8.8332 12.9 15.6
496............ 08 SURG COMBINED ANTERIOR/ 5.6871 8.4 10.8
POSTERIOR SPINAL FUSION.
497............ 08 SURG SPINAL FUSION W CC........ 2.8441 4.9 6.3
498............ 08 SURG SPINAL FUSION W/O CC...... 1.7952 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 .9836 2.3 2.8
EXCEPT SPINAL FUSION W/O
CC.
501............ 08 SURG KNEE PROCEDURES W PDX OF 2.5305 8.0 10.0
INFECTION W CC.
502............ 08 SURG KNEE PROCEDURES W PDX OF 1.5559 5.2 6.3
INFECTION W/O CC.
503............ 08 SURG KNEE PROCEDURES W/O PDX OF 1.2029 3.1 4.0
INFECTION.
504............ 22 SURG EXTENSIVE 3RD DEGREE BURNS 13.2930 24.0 31.6
W SKIN GRAFT.
505............ 22 ................... EXTENSIVE 3RD DEGREE BURNS 2.2593 2.6 5.2
W/O SKIN GRAFT.
506............ 22 ................... FULL THICKNESS BURN W SKIN 4.2007 12.5 16.8
GRAFT OR INHAL INJ W CC
OR SIG TRAUMA.
507............ 22 ................... FULL THICKNESS BURN W SKIN 1.8942 6.8 9.5
GRFT OR INHAL INJ W/O CC
OR SIG TRAUMA.
508............ 22 FULL THICKNESS BURN W/O 1.5971 5.8 8.6
SKIN GRFT OR INHAL INJ W
CC OR SIG TRAUMA.
509............ 22 FULL THICKNESS BURN W/O .8554 3.9 5.4
SKIN GRFT OR INH INJ W/O
CC OR SIG TRAUMA.
510............ 22 NON-EXTENSIVE BURNS W CC 1.3335 5.1 7.3
OR SIGNIFICANT TRAUMA.
511............ 22 NON-EXTENSIVE BURNS W/O CC .8312 3.6 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
Table 7A.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
[FY98 MEDPAR Update 03/99 Grouper V16.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36836 9.2593 2 4 7 12 19
2....................................... 7214 9.8343 3 5 7 12 19
3....................................... 7 10.5714 1 4 12 12 14
4....................................... 6080 7.4523 1 3 5 9 16
5....................................... 99334 3.4177 1 1 2 4 7
6....................................... 378 3.1138 1 1 2 4 7
7....................................... 11825 9.7856 2 4 7 12 19
8....................................... 3419 3.1120 1 1 2 4 7
9....................................... 1714 6.1190 1 3 5 8 12
10...................................... 19310 6.5665 2 3 5 8 13
11...................................... 3187 4.0446 1 2 3 5 8
12...................................... 44543 6.2764 2 3 4 7 12
13...................................... 6583 5.1621 2 3 4 6 9
14...................................... 356495 6.0058 2 3 5 7 11
15...................................... 144927 3.7348 1 2 3 5 7
16...................................... 12107 5.9202 2 3 5 7 11
17...................................... 3316 3.3685 1 2 3 4 6
18...................................... 27243 5.4721 2 3 4 7 10
19...................................... 7972 3.7881 1 2 3 5 7
20...................................... 6169 9.9651 2 5 8 13 19
21...................................... 1426 6.8079 2 3 5 9 13
22...................................... 2583 4.9001 2 2 4 6 9
23...................................... 7700 4.1762 1 2 3 5 8
24...................................... 54812 5.0310 1 2 4 6 10
[[Page 41607]]
25...................................... 24401 3.3481 1 2 3 4 6
26...................................... 29 3.5862 1 1 3 4 6
27...................................... 3652 5.2916 1 1 3 7 12
28...................................... 11240 6.0932 1 3 5 8 12
29...................................... 3756 3.6140 1 2 3 5 7
30...................................... 1 13.0000 13 13 13 13 13
31...................................... 3208 4.3332 1 2 3 5 8
32...................................... 1420 2.6901 1 1 2 3 5
34...................................... 20085 5.3312 1 2 4 6 10
35...................................... 4903 3.4852 1 2 3 4 7
36...................................... 4666 1.4256 1 1 1 1 2
37...................................... 1560 3.8372 1 1 3 4 8
38...................................... 107 2.6355 1 1 2 3 5
39...................................... 1469 1.8693 1 1 1 2 4
40...................................... 1988 3.3441 1 1 2 4 7
42...................................... 3314 2.1177 1 1 1 2 4
43...................................... 85 4.0471 1 2 2 4 7
44...................................... 1360 4.9669 2 3 4 6 9
45...................................... 2503 3.4259 1 2 3 4 6
46...................................... 3061 4.5541 1 2 3 6 9
47...................................... 1208 3.1283 1 1 2 4 6
48...................................... 1 6.0000 6 6 6 6 6
49...................................... 2282 5.0206 1 2 4 6 10
50...................................... 2831 1.9947 1 1 1 2 3
51...................................... 278 2.8921 1 1 1 3 7
52...................................... 243 1.9506 1 1 1 2 3
53...................................... 2719 3.6348 1 1 2 4 8
54...................................... 1 1.0000 1 1 1 1 1
55...................................... 1561 2.8482 1 1 2 3 6
56...................................... 587 2.8399 1 1 2 3 6
57...................................... 501 4.7665 1 1 3 5 12
59...................................... 79 2.5316 1 1 2 3 6
60...................................... 4 1.2500 1 1 1 1 2
61...................................... 239 4.8075 1 1 3 6 10
62...................................... 2 2.5000 2 2 3 3 3
63...................................... 3306 4.4574 1 2 3 5 9
64...................................... 3302 6.6087 1 2 4 8 14
65...................................... 31897 2.9095 1 1 2 4 5
66...................................... 7003 3.2128 1 2 3 4 6
67...................................... 512 3.7051 1 2 3 4 7
68...................................... 13164 4.1907 2 2 3 5 7
69...................................... 4092 3.3140 1 2 3 4 6
70...................................... 38 2.7368 1 2 2 3 5
71...................................... 109 3.4037 1 2 3 4 6
72...................................... 804 3.5162 1 2 3 4 7
73...................................... 6475 4.3396 1 2 3 5 8
74...................................... 1 2.0000 2 2 2 2 2
75...................................... 40541 9.9139 3 5 7 12 19
76...................................... 40510 11.0970 3 5 9 14 21
77...................................... 2204 5.1134 1 2 4 7 10
78...................................... 30089 7.0769 3 5 6 9 12
79...................................... 204223 8.4303 3 4 7 10 16
80...................................... 8430 5.5426 2 3 5 7 10
81...................................... 9 6.1111 1 4 6 7 9
82...................................... 67992 6.9678 2 3 5 9 14
83...................................... 6986 5.4814 2 3 4 7 10
84...................................... 1530 3.2170 1 2 3 4 6
85...................................... 21593 6.5211 2 3 5 8 13
86...................................... 1741 3.7731 1 2 3 5 7
87...................................... 67713 6.2694 1 3 5 8 12
88...................................... 398220 5.2575 2 3 4 7 9
89...................................... 510879 6.1132 2 3 5 8 11
90...................................... 46381 4.3406 2 3 4 5 7
91...................................... 64 3.9531 1 2 3 5 7
92...................................... 14187 6.2415 2 3 5 8 12
93...................................... 1438 4.2976 1 2 4 6 8
94...................................... 13076 6.3852 2 3 5 8 12
95...................................... 1514 3.6242 1 2 3 4 7
96...................................... 63671 4.7632 2 3 4 6 8
97...................................... 28420 3.7362 1 2 3 5 7
[[Page 41608]]
98...................................... 18 4.5000 2 2 3 4 5
99...................................... 19449 3.1467 1 1 2 4 6
100..................................... 7748 2.1705 1 1 2 3 4
101..................................... 20140 4.4049 1 2 3 6 8
102..................................... 4778 2.6877 1 1 2 3 5
103..................................... 547 56.5466 9 15 39 81 126
104..................................... 32842 11.8946 3 6 10 15 22
105..................................... 28697 9.4228 4 5 7 11 17
106..................................... 3906 10.9158 5 7 9 13 18
107..................................... 97459 10.4755 5 7 9 12 17
108..................................... 5282 10.9737 3 6 9 14 21
109..................................... 66660 7.8095 4 5 7 9 13
110..................................... 59376 9.5303 2 5 8 11 18
111..................................... 6606 5.6197 2 4 6 7 8
112..................................... 80818 3.8201 1 1 3 5 8
113..................................... 46280 11.9185 3 5 9 15 23
114..................................... 8726 8.1877 2 4 7 10 16
115..................................... 14436 8.4070 2 4 7 11 16
116..................................... 272446 3.9260 1 1 3 5 8
117..................................... 3511 4.1398 1 1 3 5 9
118..................................... 6439 2.8987 1 1 2 4 6
119..................................... 1554 4.8932 1 1 3 6 11
120..................................... 36832 8.2211 1 2 5 11 18
121..................................... 169544 6.5073 2 4 5 8 12
122..................................... 83742 3.9783 1 2 4 5 7
123..................................... 42140 4.4070 1 1 2 6 10
124..................................... 145335 4.4326 1 2 3 6 8
125..................................... 69830 2.8428 1 1 2 4 6
126..................................... 5297 11.8577 3 6 9 15 23
127..................................... 725354 5.3846 2 3 4 7 10
128..................................... 13964 5.8876 3 4 5 7 9
129..................................... 4522 2.8074 1 1 1 3 7
130..................................... 93798 5.8395 2 3 5 7 10
131..................................... 26368 4.4800 1 3 4 6 7
132..................................... 167891 3.0914 1 2 2 4 6
133..................................... 7132 2.3751 1 1 2 3 4
134..................................... 32871 3.3420 1 2 3 4 6
135..................................... 7556 4.3634 1 2 3 5 8
136..................................... 1151 2.9427 1 1 2 4 6
138..................................... 204380 3.9935 1 2 3 5 8
139..................................... 74952 2.5369 1 1 2 3 5
140..................................... 90171 2.8048 1 1 2 3 5
141..................................... 85551 3.7306 1 2 3 5 7
142..................................... 40836 2.7078 1 1 2 3 5
143..................................... 174426 2.1903 1 1 2 3 4
144..................................... 77995 5.3213 1 2 4 7 11
145..................................... 6796 2.8261 1 1 2 4 5
146..................................... 12246 10.3034 5 7 9 12 17
147..................................... 2305 6.7080 3 5 7 8 10
148..................................... 143500 12.1060 5 7 10 14 21
149..................................... 16362 6.7222 4 5 6 8 10
150..................................... 22214 11.0307 4 6 9 14 19
151..................................... 4386 5.9758 2 3 6 8 11
152..................................... 4778 8.3024 3 5 7 10 14
153..................................... 1793 5.6168 3 4 5 7 8
154..................................... 32409 13.1933 4 7 10 16 25
155..................................... 5603 4.5138 1 2 4 6 8
156..................................... 5 10.6000 2 2 11 13 22
157..................................... 8595 5.5779 1 2 4 7 11
158..................................... 4411 2.6384 1 1 2 3 5
159..................................... 17429 4.9651 1 2 4 6 10
160..................................... 10531 2.7382 1 1 2 4 5
161..................................... 12611 4.1561 1 2 3 5 9
162..................................... 6778 2.0031 1 1 1 2 4
163..................................... 6 3.3333 1 3 3 5 5
164..................................... 5103 8.5348 4 5 7 10 14
165..................................... 1821 4.9368 2 3 5 6 8
166..................................... 3423 5.1440 2 3 4 6 10
167..................................... 2688 2.7742 1 2 2 3 5
168..................................... 1682 4.6843 1 2 3 6 10
[[Page 41609]]
169..................................... 866 2.5208 1 1 2 3 5
170..................................... 12216 11.2317 2 5 8 14 22
171..................................... 1060 4.7679 1 2 4 6 9
172..................................... 32209 6.9183 2 3 5 9 14
173..................................... 2318 3.8007 1 1 3 5 8
174..................................... 250706 4.8426 2 3 4 6 9
175..................................... 25360 2.9403 1 2 3 4 5
176..................................... 17698 5.2788 2 3 4 6 10
177..................................... 10596 4.4886 2 2 4 6 8
178..................................... 3611 3.1742 1 2 3 4 6
179..................................... 12438 6.1530 2 3 5 8 12
180..................................... 90784 5.3432 2 3 4 7 10
181..................................... 24531 3.4095 1 2 3 4 6
182..................................... 236683 4.3360 1 2 3 5 8
183..................................... 77376 2.9902 1 1 2 4 6
184..................................... 89 3.0225 1 1 2 3 7
185..................................... 4281 4.5359 1 2 3 6 9
186..................................... 7 3.2857 1 2 3 4 4
187..................................... 865 3.9052 1 2 3 5 8
188..................................... 76094 5.5497 1 2 4 7 11
189..................................... 9709 3.2163 1 1 2 4 6
190..................................... 69 5.6087 1 2 4 7 9
191..................................... 9760 14.1831 4 7 10 17 28
192..................................... 838 7.0251 2 4 6 9 11
193..................................... 6564 12.6140 5 7 10 15 23
194..................................... 743 6.5639 2 4 6 8 11
195..................................... 5935 9.9928 4 6 8 12 17
196..................................... 1267 5.6780 2 4 5 7 9
197..................................... 23028 8.6261 3 5 7 10 15
198..................................... 6393 4.5098 2 3 4 6 8
199..................................... 1894 9.6172 2 4 7 13 19
200..................................... 1196 10.9983 2 4 8 14 22
201..................................... 1515 14.0614 4 6 11 18 28
202..................................... 27560 6.5773 2 3 5 8 13
203..................................... 30112 6.7066 2 3 5 9 13
204..................................... 55486 5.9715 2 3 5 7 11
205..................................... 23295 6.3206 2 3 5 8 12
206..................................... 1730 4.0694 1 2 3 5 8
207..................................... 32811 5.1164 1 2 4 6 10
208..................................... 9895 2.9051 1 1 2 4 6
209..................................... 355057 5.1351 3 3 4 6 8
210..................................... 134595 6.7578 3 4 6 8 11
211..................................... 29234 4.9046 3 3 4 6 7
212..................................... 8 3.6250 1 2 4 5 5
213..................................... 7936 8.3266 2 4 6 10 17
216..................................... 6080 9.5355 2 4 7 12 19
217..................................... 19791 12.6226 3 5 9 15 27
218..................................... 22787 5.2827 2 3 4 6 10
219..................................... 19533 3.1973 1 2 3 4 5
220..................................... 4 9.2500 1 1 6 12 18
223..................................... 17962 2.5659 1 1 2 3 5
224..................................... 8009 2.0411 1 1 2 3 4
225..................................... 5837 4.4655 1 2 3 6 9
226..................................... 5298 5.9932 1 2 4 8 12
227..................................... 4340 2.7548 1 1 2 3 5
228..................................... 2585 3.5791 1 1 2 4 8
229..................................... 1157 2.4408 1 1 2 3 4
230..................................... 2300 4.7948 1 2 3 6 10
231..................................... 11018 4.6331 1 2 3 6 10
232..................................... 535 4.0748 1 1 2 5 9
233..................................... 4876 7.5070 2 3 5 9 16
234..................................... 2587 3.4519 1 2 3 4 7
235..................................... 5406 5.0218 1 2 4 6 9
236..................................... 39509 4.9105 1 3 4 6 9
237..................................... 1711 3.5634 1 2 3 4 6
238..................................... 7793 8.3853 3 4 6 10 16
239..................................... 55949 6.2607 2 3 5 8 12
240..................................... 12987 6.6413 2 3 5 8 13
241..................................... 3039 4.0234 1 2 3 5 7
242..................................... 2683 6.6347 2 3 5 8 13
[[Page 41610]]
243..................................... 84670 4.7255 1 3 4 6 9
244..................................... 12703 4.8316 1 3 4 6 9
245..................................... 4970 3.5777 1 2 3 4 7
246..................................... 1351 3.7187 1 2 3 5 7
247..................................... 14132 3.4177 1 2 3 4 7
248..................................... 9001 4.6185 1 2 4 6 9
249..................................... 10992 3.5375 1 1 2 4 7
250..................................... 3653 4.1237 1 2 3 5 8
251..................................... 2300 2.8961 1 1 2 4 5
253..................................... 19185 4.7469 1 3 4 6 9
254..................................... 10028 3.2017 1 2 3 4 6
256..................................... 5967 5.1324 1 2 4 6 10
257..................................... 19522 2.9195 1 2 2 3 5
258..................................... 16906 2.0608 1 1 2 2 3
259..................................... 3748 2.7620 1 1 2 3 6
260..................................... 4729 1.4743 1 1 1 2 2
261..................................... 1803 2.1780 1 1 1 3 4
262..................................... 653 3.9326 1 1 3 5 8
263..................................... 26034 11.3386 3 5 8 14 22
264..................................... 3840 6.9898 2 3 5 8 13
265..................................... 4133 6.9557 1 2 4 8 14
266..................................... 2546 3.3496 1 1 2 4 7
267..................................... 241 4.0788 1 1 3 5 9
268..................................... 897 3.8060 1 1 2 4 8
269..................................... 8851 7.8528 2 3 6 10 16
270..................................... 2749 3.1364 1 1 2 4 7
271..................................... 22655 7.0989 3 4 6 8 13
272..................................... 5664 6.2920 2 3 5 7 12
273..................................... 1357 4.3839 1 2 3 5 8
274..................................... 2464 6.5345 1 3 5 8 13
275..................................... 208 3.8894 1 1 2 5 8
276..................................... 1001 4.3906 1 2 4 5 8
277..................................... 84629 5.7563 2 3 5 7 10
278..................................... 27776 4.4282 2 3 4 5 8
279..................................... 11 5.0909 1 3 4 5 8
280..................................... 15056 4.2132 1 2 3 5 8
281..................................... 6510 3.0602 1 1 3 4 6
282..................................... 1 3.0000 3 3 3 3 3
283..................................... 5366 4.7128 1 2 4 6 9
284..................................... 1799 3.1957 1 1 3 4 6
285..................................... 6035 10.5781 3 5 8 13 21
286..................................... 2166 6.6307 2 3 5 8 13
287..................................... 6069 10.3935 3 5 7 12 20
288..................................... 2020 5.7025 3 3 4 6 9
289..................................... 4812 3.0247 1 1 2 3 6
290..................................... 8605 2.4284 1 1 2 3 4
291..................................... 76 2.0132 1 1 1 2 3
292..................................... 4847 10.4246 2 4 8 13 21
293..................................... 323 4.9567 1 2 4 6 11
294..................................... 84534 4.7447 1 2 4 6 9
295..................................... 3469 3.8665 1 2 3 5 7
296..................................... 234511 5.2830 2 3 4 6 10
297..................................... 36737 3.5367 1 2 3 4 6
298..................................... 90 3.4889 1 1 2 4 7
299..................................... 1124 5.3932 1 2 4 7 11
300..................................... 16177 6.2295 2 3 5 8 12
301..................................... 2822 3.5666 1 2 3 4 7
302..................................... 8038 9.6920 5 6 7 11 17
303..................................... 20077 8.7449 4 5 7 10 15
304..................................... 12388 8.8926 2 4 7 11 18
305..................................... 2795 3.9030 1 2 3 5 7
306..................................... 9132 5.4262 1 2 3 7 12
307..................................... 2186 2.3605 1 1 2 3 4
308..................................... 8285 6.1389 1 2 4 8 13
309..................................... 4064 2.5226 1 1 2 3 5
310..................................... 25390 4.3348 1 2 3 5 9
311..................................... 7973 1.9387 1 1 1 2 4
312..................................... 1665 4.5808 1 1 3 6 10
313..................................... 643 2.3919 1 1 2 3 5
314..................................... 1 2.0000 2 2 2 2 2
[[Page 41611]]
315..................................... 28422 7.8309 1 2 5 10 17
316..................................... 94820 6.6602 2 3 5 8 13
317..................................... 801 3.1898 1 1 2 3 6
318..................................... 6098 5.9802 1 3 4 8 12
319..................................... 457 2.8665 1 1 2 4 6
320..................................... 183745 5.4047 2 3 4 7 10
321..................................... 26994 3.8755 2 2 3 5 7
322..................................... 68 3.6618 1 2 3 4 6
323..................................... 16793 3.2042 1 1 2 4 6
324..................................... 7668 1.9287 1 1 1 2 4
325..................................... 7806 3.8663 1 2 3 5 7
326..................................... 2390 2.7046 1 1 2 3 5
327..................................... 9 3.4444 1 2 3 6 6
328..................................... 691 3.7019 1 2 3 5 7
329..................................... 108 2.4259 1 1 1 3 5
331..................................... 45316 5.5090 1 3 4 7 11
332..................................... 4707 3.4391 1 1 3 4 7
333..................................... 267 4.4082 1 2 3 5 10
334..................................... 14231 4.9975 3 3 4 6 8
335..................................... 10417 3.5491 2 3 3 4 5
336..................................... 46652 3.6099 1 2 3 4 7
337..................................... 31028 2.2136 1 1 2 3 3
338..................................... 2147 5.1202 1 2 3 7 12
339..................................... 1813 4.4865 1 1 3 6 10
340..................................... 2 1.0000 1 1 1 1 1
341..................................... 4093 3.2057 1 1 2 3 6
342..................................... 880 3.4966 1 2 2 4 7
344..................................... 4123 2.3546 1 1 1 2 5
345..................................... 1236 3.7055 1 1 2 4 8
346..................................... 4984 5.7153 1 3 4 7 11
347..................................... 376 3.1303 1 1 2 4 7
348..................................... 3100 4.1839 1 2 3 5 8
349..................................... 600 2.5250 1 1 2 3 5
350..................................... 6572 4.3821 2 2 4 5 8
352..................................... 698 3.9169 1 1 3 5 7
353..................................... 2712 7.0749 3 4 5 8 13
354..................................... 9042 5.7710 3 3 4 6 10
355..................................... 5962 3.4074 2 3 3 4 5
356..................................... 28380 2.5532 1 2 2 3 4
357..................................... 6098 8.6471 3 5 7 10 16
358..................................... 25005 4.4148 2 3 3 5 7
359..................................... 29669 2.8899 2 2 3 3 4
360..................................... 17416 3.0307 1 2 3 3 5
361..................................... 478 3.3703 1 1 2 4 7
362..................................... 1 1.0000 1 1 1 1 1
363..................................... 3606 3.2887 1 2 2 3 7
364..................................... 1831 3.5281 1 1 2 4 7
365..................................... 2018 7.0927 2 3 5 9 15
366..................................... 4378 6.7106 1 3 5 8 14
367..................................... 476 2.9853 1 1 2 3 6
368..................................... 2781 6.2312 2 3 5 8 12
369..................................... 2776 3.2248 1 1 2 4 6
370..................................... 1166 5.9185 3 3 4 5 9
371..................................... 1248 3.6330 2 3 3 4 5
372..................................... 888 3.4651 1 2 2 3 5
373..................................... 3969 2.1464 1 2 2 2 3
374..................................... 140 3.1714 1 2 2 3 4
375..................................... 6 3.8333 1 1 2 5 5
376..................................... 205 3.4439 1 1 2 3 7
377..................................... 35 5.4000 1 1 3 5 13
378..................................... 177 2.7514 1 2 2 3 4
379..................................... 359 3.0836 1 1 2 3 6
380..................................... 91 1.8571 1 1 1 2 3
381..................................... 185 2.3297 1 1 1 3 5
382..................................... 56 1.2857 1 1 1 1 2
383..................................... 1526 4.0216 1 2 3 5 8
384..................................... 123 2.4065 1 1 2 2 5
385..................................... 1 2.0000 2 2 2 2 2
389..................................... 8 6.7500 1 5 5 7 12
390..................................... 9 3.3333 1 1 4 4 5
[[Page 41612]]
392..................................... 2665 9.6432 3 4 7 12 20
394..................................... 1796 6.8135 1 2 4 8 15
395..................................... 77862 4.5487 1 2 3 6 9
396..................................... 17 3.1765 1 1 2 4 6
397..................................... 19299 5.3534 1 2 4 7 11
398..................................... 18648 5.9575 2 3 5 7 11
399..................................... 1513 3.7198 1 2 3 5 7
400..................................... 7367 9.1258 2 3 6 11 20
401..................................... 6271 11.0518 2 5 8 14 22
402..................................... 1464 4.1735 1 1 3 5 9
403..................................... 36559 8.0187 2 3 6 10 16
404..................................... 4130 4.3341 1 2 3 6 9
406..................................... 2851 10.1371 3 5 8 13 21
407..................................... 677 4.1773 1 2 3 5 7
408..................................... 2412 7.7363 1 2 5 10 18
409..................................... 3775 6.1094 2 3 4 6 12
410..................................... 50278 3.5715 1 2 3 4 6
411..................................... 20 2.3500 1 1 2 3 4
412..................................... 28 2.0000 1 1 1 2 4
413..................................... 7463 7.4528 2 3 6 10 15
414..................................... 693 4.1616 1 2 3 5 9
415..................................... 42974 14.0677 4 6 11 17 28
416..................................... 215135 7.3072 2 4 6 9 14
417..................................... 42 4.6905 1 2 3 6 10
418..................................... 22536 6.0572 2 3 5 7 11
419..................................... 15983 4.9037 2 2 4 6 9
420..................................... 3053 3.6495 1 2 3 5 7
421..................................... 13182 3.9219 1 2 3 5 7
422..................................... 93 2.9785 1 1 2 4 6
423..................................... 9177 7.6953 2 3 6 9 16
424..................................... 1398 14.0250 2 5 10 17 27
425..................................... 15652 4.0606 1 2 3 5 8
426..................................... 4620 4.6361 1 2 3 6 9
427..................................... 1678 4.9362 1 2 3 6 11
428..................................... 871 6.8726 1 2 4 8 15
429..................................... 29605 6.5253 2 3 5 8 13
430..................................... 59517 8.3640 2 3 6 11 17
431..................................... 313 7.1374 1 3 5 8 13
432..................................... 442 5.1833 1 2 3 5 10
433..................................... 6368 3.0974 1 1 2 4 6
434..................................... 21885 5.1509 1 2 4 6 10
435..................................... 14675 4.3381 1 2 4 5 8
436..................................... 3324 13.5096 4 7 12 21 27
437..................................... 11674 8.9895 3 5 8 11 15
439..................................... 1202 7.5166 1 3 5 9 15
440..................................... 5340 8.9891 2 3 6 11 19
441..................................... 571 3.0490 1 1 2 4 7
442..................................... 15865 7.8969 1 3 6 10 16
443..................................... 3389 3.2762 1 1 2 4 7
444..................................... 5071 4.2901 1 2 3 5 8
445..................................... 2242 2.9942 1 1 2 4 6
447..................................... 4724 2.5356 1 1 2 3 5
448..................................... 2 1.5000 1 1 2 2 2
449..................................... 26249 3.7076 1 1 3 4 7
450..................................... 6361 2.0483 1 1 1 2 4
451..................................... 4 3.7500 1 1 2 4 8
452..................................... 22505 4.9207 1 2 3 6 10
453..................................... 4265 2.8802 1 1 2 4 5
454..................................... 6007 4.4748 1 2 3 5 9
455..................................... 994 2.5905 1 1 2 3 5
461..................................... 3500 4.5026 1 1 2 5 11
462..................................... 11041 12.2571 4 6 10 16 23
463..................................... 16720 4.2907 1 2 3 5 8
464..................................... 4504 3.1854 1 2 3 4 6
465..................................... 204 3.6029 1 1 1 4 7
466..................................... 1771 4.0011 1 1 2 4 8
467..................................... 1238 3.2504 1 1 2 4 6
468..................................... 60480 13.2738 3 6 10 17 26
471..................................... 11960 5.6279 3 3 5 6 9
473..................................... 8085 13.1116 2 3 7 19 33
[[Page 41613]]
475..................................... 110336 11.1055 2 5 9 15 22
476..................................... 5200 11.6544 2 6 10 15 21
477..................................... 27191 8.0489 1 3 6 10 17
478..................................... 119489 7.2839 1 3 5 9 15
479..................................... 21407 3.7730 1 2 3 5 7
480..................................... 459 23.1046 7 11 16 28 48
481..................................... 274 24.8759 10 19 23 30 40
482..................................... 6476 12.8700 4 7 10 15 23
483..................................... 43362 38.9597 14 21 32 48 71
484..................................... 416 13.1466 1 5 10 18 27
485..................................... 3232 9.1894 4 5 7 11 17
486..................................... 2171 12.1935 1 5 10 16 24
487..................................... 3766 7.3221 1 3 6 9 15
488..................................... 794 18.0416 3 7 13 23 37
489..................................... 14199 8.7326 2 3 6 11 18
490..................................... 4835 5.2709 1 2 4 7 10
491..................................... 11661 3.5467 2 2 3 4 6
492..................................... 2597 16.8063 4 5 11 27 35
493..................................... 55406 5.7168 1 3 5 7 11
494..................................... 26219 2.5095 1 1 2 3 5
495..................................... 143 15.6434 6 8 12 22 29
496..................................... 1111 10.7885 4 5 8 13 21
497..................................... 23280 6.2649 2 3 5 7 11
498..................................... 16782 3.4122 1 2 3 4 6
499..................................... 33561 4.8046 1 2 4 6 9
500..................................... 40918 2.7633 1 1 2 3 5
501..................................... 1994 10.0035 4 5 8 12 19
502..................................... 554 6.2708 3 4 5 7 11
503..................................... 5907 3.9661 1 2 3 5 7
504..................................... 123 31.6260 9 15 26 40 63
505..................................... 158 5.2405 1 1 2 6 13
506..................................... 1117 16.4270 4 7 13 22 33
507..................................... 415 9.5133 2 4 8 13 20
508..................................... 1111 7.3987 2 3 5 9 14
509..................................... 504 4.9187 1 2 3 6 11
510..................................... 1026 6.9688 2 3 5 8 15
511..................................... 307 4.8143 1 2 3 6 9
----------------
11262531
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7B.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
[FY98 MEDPAR Update 03/99 Grouper V17.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36836 9.2593 2 4 7 12 19
2....................................... 7214 9.8343 3 5 7 12 19
3....................................... 7 10.5714 1 4 12 12 14
4....................................... 6080 7.4523 1 3 5 9 16
5....................................... 99334 3.4177 1 1 2 4 7
6....................................... 378 3.1138 1 1 2 4 7
7....................................... 12698 10.3438 2 4 7 13 21
8....................................... 3450 3.1467 1 1 2 4 7
9....................................... 1714 6.1190 1 3 5 8 12
10...................................... 19309 6.5667 2 3 5 8 13
11...................................... 3187 4.0446 1 2 3 5 8
12...................................... 44543 6.2764 2 3 4 7 12
13...................................... 6583 5.1621 2 3 4 6 9
14...................................... 356487 6.0057 2 3 5 7 11
15...................................... 144920 3.7348 1 2 3 5 7
16...................................... 12105 5.9197 2 3 5 7 11
17...................................... 3316 3.3685 1 2 3 4 6
18...................................... 27243 5.4721 2 3 4 7 10
19...................................... 7971 3.7885 1 2 3 5 7
20...................................... 6169 9.9651 2 5 8 13 19
21...................................... 1426 6.8079 2 3 5 9 13
22...................................... 2583 4.9001 2 2 4 6 9
23...................................... 7698 4.1758 1 2 3 5 8
[[Page 41614]]
24...................................... 54812 5.0310 1 2 4 6 10
25...................................... 24400 3.3482 1 2 3 4 6
26...................................... 29 3.5862 1 1 3 4 6
27...................................... 3652 5.2916 1 1 3 7 12
28...................................... 11239 6.0937 1 3 5 8 12
29...................................... 3756 3.6140 1 2 3 5 7
30...................................... 1 13.0000 13 13 13 13 13
31...................................... 3208 4.3332 1 2 3 5 8
32...................................... 1420 2.6901 1 1 2 3 5
34...................................... 20085 5.3312 1 2 4 6 10
35...................................... 4903 3.4852 1 2 3 4 7
36...................................... 4666 1.4256 1 1 1 1 2
37...................................... 1560 3.8372 1 1 3 4 8
38...................................... 107 2.6355 1 1 2 3 5
39...................................... 1469 1.8693 1 1 1 2 4
40...................................... 1988 3.3441 1 1 2 4 7
42...................................... 3314 2.1177 1 1 1 2 4
43...................................... 85 4.0471 1 2 2 4 7
44...................................... 1360 4.9669 2 3 4 6 9
45...................................... 2503 3.4259 1 2 3 4 6
46...................................... 3061 4.5541 1 2 3 6 9
47...................................... 1208 3.1283 1 1 2 4 6
48...................................... 1 6.0000 6 6 6 6 6
49...................................... 2282 5.0206 1 2 4 6 10
50...................................... 2831 1.9947 1 1 1 2 3
51...................................... 278 2.8921 1 1 1 3 7
52...................................... 159 1.8868 1 1 1 2 3
53...................................... 2719 3.6348 1 1 2 4 8
54...................................... 1 1.0000 1 1 1 1 1
55...................................... 1561 2.8482 1 1 2 3 6
56...................................... 587 2.8399 1 1 2 3 6
57...................................... 680 4.4588 1 1 2 5 11
59...................................... 79 2.5316 1 1 2 3 6
60...................................... 4 1.2500 1 1 1 1 2
61...................................... 239 4.8075 1 1 3 6 10
62...................................... 2 2.5000 2 2 3 3 3
63...................................... 3306 4.4574 1 2 3 5 9
64...................................... 3302 6.6087 1 2 4 8 14
65...................................... 31895 2.9094 1 1 2 4 5
66...................................... 7002 3.2129 1 2 3 4 6
67...................................... 512 3.7051 1 2 3 4 7
68...................................... 13163 4.1908 2 2 3 5 7
69...................................... 4092 3.3140 1 2 3 4 6
70...................................... 38 2.7368 1 2 2 3 5
71...................................... 109 3.4037 1 2 3 4 6
72...................................... 804 3.5162 1 2 3 4 7
73...................................... 6475 4.3396 1 2 3 5 8
74...................................... 1 2.0000 2 2 2 2 2
75...................................... 40541 9.9139 3 5 7 12 19
76...................................... 41055 11.1287 3 5 9 14 21
77...................................... 2213 5.1148 1 2 4 7 10
78...................................... 30088 7.0769 3 5 6 9 12
79...................................... 204216 8.4304 3 4 7 10 16
80...................................... 8429 5.5429 2 3 5 7 10
81...................................... 9 6.1111 1 4 6 7 9
82...................................... 67991 6.9678 2 3 5 9 14
83...................................... 6985 5.4805 2 3 4 7 10
84...................................... 1530 3.2170 1 2 3 4 6
85...................................... 21592 6.5212 2 3 5 8 13
86...................................... 1741 3.7731 1 2 3 5 7
87...................................... 67711 6.2696 1 3 5 8 12
88...................................... 398204 5.2576 2 3 4 7 9
89...................................... 510853 6.1132 2 3 5 8 11
90...................................... 46380 4.3406 2 3 4 5 7
91...................................... 64 3.9531 1 2 3 5 7
92...................................... 14187 6.2415 2 3 5 8 12
93...................................... 1438 4.2976 1 2 4 6 8
94...................................... 13076 6.3852 2 3 5 8 12
95...................................... 1514 3.6242 1 2 3 4 7
96...................................... 63669 4.7632 2 3 4 6 8
[[Page 41615]]
97...................................... 28418 3.7363 1 2 3 5 7
98...................................... 18 4.5000 2 2 3 4 5
99...................................... 19447 3.1469 1 1 2 4 6
100..................................... 7748 2.1705 1 1 2 3 4
101..................................... 20139 4.4047 1 2 3 6 8
102..................................... 4778 2.6877 1 1 2 3 5
103..................................... 547 56.5466 9 15 39 81 126
104..................................... 32842 11.8946 3 6 10 15 22
105..................................... 28697 9.4228 4 5 7 11 17
106..................................... 3906 10.9158 5 7 9 13 18
107..................................... 97459 10.4755 5 7 9 12 17
108..................................... 5282 10.9737 3 6 9 14 21
109..................................... 66660 7.8095 4 5 7 9 13
110..................................... 59376 9.5303 2 5 8 11 18
111..................................... 6606 5.6197 2 4 6 7 8
112..................................... 80818 3.8201 1 1 3 5 8
113..................................... 46280 11.9185 3 5 9 15 23
114..................................... 8726 8.1877 2 4 7 10 16
115..................................... 14436 8.4070 2 4 7 11 16
116..................................... 272446 3.9260 1 1 3 5 8
117..................................... 3511 4.1398 1 1 3 5 9
118..................................... 6439 2.8987 1 1 2 4 6
119..................................... 1554 4.8932 1 1 3 6 11
120..................................... 36921 8.2184 1 2 5 11 18
121..................................... 169542 6.5073 2 4 5 8 12
122..................................... 83737 3.9785 1 2 4 5 7
123..................................... 42138 4.4072 1 1 2 6 10
124..................................... 145335 4.4326 1 2 3 6 8
125..................................... 69830 2.8428 1 1 2 4 6
126..................................... 5297 11.8577 3 6 9 15 23
127..................................... 725343 5.3846 2 3 4 7 10
128..................................... 13957 5.8882 3 4 5 7 9
129..................................... 4522 2.8074 1 1 1 3 7
130..................................... 93795 5.8394 2 3 5 7 10
131..................................... 26365 4.4803 1 3 4 6 7
132..................................... 167887 3.0915 1 2 2 4 6
133..................................... 7131 2.3751 1 1 2 3 4
134..................................... 32871 3.3420 1 2 3 4 6
135..................................... 7556 4.3634 1 2 3 5 8
136..................................... 1151 2.9427 1 1 2 4 6
138..................................... 204377 3.9935 1 2 3 5 8
139..................................... 74949 2.5370 1 1 2 3 5
140..................................... 90166 2.8049 1 1 2 3 5
141..................................... 85549 3.7307 1 2 3 5 7
142..................................... 40835 2.7078 1 1 2 3 5
143..................................... 174420 2.1903 1 1 2 3 4
144..................................... 77994 5.3212 1 2 4 7 11
145..................................... 6796 2.8261 1 1 2 4 5
146..................................... 12246 10.3034 5 7 9 12 17
147..................................... 2305 6.7080 3 5 7 8 10
148..................................... 143500 12.1060 5 7 10 14 21
149..................................... 16362 6.7222 4 5 6 8 10
150..................................... 22213 11.0306 4 6 9 14 19
151..................................... 4386 5.9758 2 3 6 8 11
152..................................... 4778 8.3024 3 5 7 10 14
153..................................... 1793 5.6168 3 4 5 7 8
154..................................... 32408 13.1935 4 7 10 16 25
155..................................... 5602 4.5059 1 2 4 6 8
156..................................... 5 10.6000 2 2 11 13 22
157..................................... 8593 5.5783 1 2 4 7 11
158..................................... 4411 2.6384 1 1 2 3 5
159..................................... 17429 4.9651 1 2 4 6 10
160..................................... 10531 2.7382 1 1 2 4 5
161..................................... 12610 4.1558 1 2 3 5 9
162..................................... 6778 2.0031 1 1 1 2 4
163..................................... 6 3.3333 1 3 3 5 5
164..................................... 5103 8.5348 4 5 7 10 14
165..................................... 1821 4.9368 2 3 5 6 8
166..................................... 3422 5.1441 2 3 4 6 10
167..................................... 2688 2.7742 1 2 2 3 5
[[Page 41616]]
168..................................... 1624 4.6188 1 2 3 6 9
169..................................... 829 2.5223 1 1 2 3 5
170..................................... 12216 11.2317 2 5 8 14 22
171..................................... 1060 4.7679 1 2 4 6 9
172..................................... 32207 6.9186 2 3 5 9 14
173..................................... 2318 3.8007 1 1 3 5 8
174..................................... 250699 4.8426 2 3 4 6 9
175..................................... 25358 2.9404 1 2 3 4 5
176..................................... 17698 5.2788 2 3 4 6 10
177..................................... 10595 4.4886 2 2 4 6 8
178..................................... 3611 3.1742 1 2 3 4 6
179..................................... 12437 6.1533 2 3 5 8 12
180..................................... 90780 5.3431 2 3 4 7 10
181..................................... 24531 3.4095 1 2 3 4 6
182..................................... 236680 4.3360 1 2 3 5 8
183..................................... 77375 2.9902 1 1 2 4 6
184..................................... 89 3.0225 1 1 2 3 7
185..................................... 4281 4.5359 1 2 3 6 9
186..................................... 7 3.2857 1 2 3 4 4
187..................................... 865 3.9052 1 2 3 5 8
188..................................... 76090 5.5497 1 2 4 7 11
189..................................... 9709 3.2163 1 1 2 4 6
190..................................... 69 5.6087 1 2 4 7 9
191..................................... 9760 14.1831 4 7 10 17 28
192..................................... 838 7.0251 2 4 6 9 11
193..................................... 6564 12.6140 5 7 10 15 23
194..................................... 743 6.5639 2 4 6 8 11
195..................................... 5935 9.9928 4 6 8 12 17
196..................................... 1267 5.6780 2 4 5 7 9
197..................................... 23028 8.6261 3 5 7 10 15
198..................................... 6393 4.5098 2 3 4 6 8
199..................................... 1894 9.6172 2 4 7 13 19
200..................................... 1196 10.9983 2 4 8 14 22
201..................................... 1515 14.0614 4 6 11 18 28
202..................................... 27560 6.5773 2 3 5 8 13
203..................................... 30111 6.7062 2 3 5 9 13
204..................................... 55485 5.9715 2 3 5 7 11
205..................................... 23295 6.3206 2 3 5 8 12
206..................................... 1730 4.0694 1 2 3 5 8
207..................................... 32809 5.1165 1 2 4 6 10
208..................................... 9894 2.9049 1 1 2 4 6
209..................................... 355054 5.1351 3 3 4 6 8
210..................................... 134594 6.7578 3 4 6 8 11
211..................................... 29233 4.9046 3 3 4 6 7
212..................................... 8 3.6250 1 2 4 5 5
213..................................... 7936 8.3266 2 4 6 10 17
216..................................... 6080 9.5355 2 4 7 12 19
217..................................... 19791 12.6226 3 5 9 15 27
218..................................... 22787 5.2827 2 3 4 6 10
219..................................... 19533 3.1973 1 2 3 4 5
220..................................... 4 9.2500 1 1 6 12 18
223..................................... 17960 2.5661 1 1 2 3 5
224..................................... 8009 2.0411 1 1 2 3 4
225..................................... 5837 4.4655 1 2 3 6 9
226..................................... 5297 5.9941 1 2 4 8 12
227..................................... 4340 2.7548 1 1 2 3 5
228..................................... 2585 3.5791 1 1 2 4 8
229..................................... 1157 2.4408 1 1 2 3 4
230..................................... 2300 4.7948 1 2 3 6 10
231..................................... 11018 4.6331 1 2 3 6 10
232..................................... 535 4.0748 1 1 2 5 9
233..................................... 4876 7.5070 2 3 5 9 16
234..................................... 2587 3.4519 1 2 3 4 7
235..................................... 5406 5.0218 1 2 4 6 9
236..................................... 39504 4.9102 1 3 4 6 9
237..................................... 1711 3.5634 1 2 3 4 6
238..................................... 7793 8.3853 3 4 6 10 16
239..................................... 55949 6.2607 2 3 5 8 12
240..................................... 12987 6.6413 2 3 5 8 13
241..................................... 3039 4.0234 1 2 3 5 7
[[Page 41617]]
242..................................... 2683 6.6347 2 3 5 8 13
243..................................... 84667 4.7255 1 3 4 6 9
244..................................... 12703 4.8316 1 3 4 6 9
245..................................... 4969 3.5768 1 2 3 4 7
246..................................... 1351 3.7187 1 2 3 5 7
247..................................... 14131 3.4179 1 2 3 4 7
248..................................... 9001 4.6185 1 2 4 6 9
249..................................... 10990 3.5379 1 1 2 4 7
250..................................... 3653 4.1237 1 2 3 5 8
251..................................... 2300 2.8961 1 1 2 4 5
253..................................... 19183 4.7470 1 3 4 6 9
254..................................... 10028 3.2017 1 2 3 4 6
256..................................... 5967 5.1324 1 2 4 6 10
257..................................... 19521 2.9195 1 2 2 3 5
258..................................... 16906 2.0608 1 1 2 2 3
259..................................... 3748 2.7620 1 1 2 3 6
260..................................... 4729 1.4743 1 1 1 2 2
261..................................... 1803 2.1780 1 1 1 3 4
262..................................... 653 3.9326 1 1 3 5 8
263..................................... 26033 11.3385 3 5 8 14 22
264..................................... 3840 6.9898 2 3 5 8 13
265..................................... 4133 6.9557 1 2 4 8 14
266..................................... 2546 3.3496 1 1 2 4 7
267..................................... 241 4.0788 1 1 3 5 9
268..................................... 897 3.8060 1 1 2 4 8
269..................................... 8851 7.8528 2 3 6 10 16
270..................................... 2749 3.1364 1 1 2 4 7
271..................................... 22654 7.0990 3 4 6 8 13
272..................................... 5663 6.2930 2 3 5 7 12
273..................................... 1357 4.3839 1 2 3 5 8
274..................................... 2464 6.5345 1 3 5 8 13
275..................................... 208 3.8894 1 1 2 5 8
276..................................... 1001 4.3906 1 2 4 5 8
277..................................... 84624 5.7564 2 3 5 7 10
278..................................... 27774 4.4283 2 3 4 5 8
279..................................... 11 5.0909 1 3 4 5 8
280..................................... 15054 4.2136 1 2 3 5 8
281..................................... 6510 3.0602 1 1 3 4 6
282..................................... 1 3.0000 3 3 3 3 3
283..................................... 5366 4.7128 1 2 4 6 9
284..................................... 1799 3.1957 1 1 3 4 6
285..................................... 6035 10.5781 3 5 8 13 21
286..................................... 2166 6.6307 2 3 5 8 13
287..................................... 6069 10.3935 3 5 7 12 20
288..................................... 2020 5.7025 3 3 4 6 9
289..................................... 4812 3.0247 1 1 2 3 6
290..................................... 8605 2.4284 1 1 2 3 4
291..................................... 76 2.0132 1 1 1 2 3
292..................................... 4847 10.4246 2 4 8 13 21
293..................................... 323 4.9567 1 2 4 6 11
294..................................... 84531 4.7447 1 2 4 6 9
295..................................... 3469 3.8665 1 2 3 5 7
296..................................... 234504 5.2830 2 3 4 6 10
297..................................... 36736 3.5367 1 2 3 4 6
298..................................... 90 3.4889 1 1 2 4 7
299..................................... 1124 5.3932 1 2 4 7 11
300..................................... 16177 6.2295 2 3 5 8 12
301..................................... 2822 3.5666 1 2 3 4 7
302..................................... 8038 9.6920 5 6 7 11 17
303..................................... 20077 8.7449 4 5 7 10 15
304..................................... 12388 8.8926 2 4 7 11 18
305..................................... 2795 3.9030 1 2 3 5 7
306..................................... 9132 5.4262 1 2 3 7 12
307..................................... 2186 2.3605 1 1 2 3 4
308..................................... 8285 6.1389 1 2 4 8 13
309..................................... 4064 2.5226 1 1 2 3 5
310..................................... 25390 4.3348 1 2 3 5 9
311..................................... 7973 1.9387 1 1 1 2 4
312..................................... 1665 4.5808 1 1 3 6 10
313..................................... 643 2.3919 1 1 2 3 5
[[Page 41618]]
314..................................... 1 2.0000 2 2 2 2 2
315..................................... 28422 7.8309 1 2 5 10 17
316..................................... 94819 6.6602 2 3 5 8 13
317..................................... 801 3.1898 1 1 2 3 6
318..................................... 6096 5.9810 1 3 4 8 12
319..................................... 457 2.8665 1 1 2 4 6
320..................................... 183743 5.4047 2 3 4 7 10
321..................................... 26994 3.8755 2 2 3 5 7
322..................................... 68 3.6618 1 2 3 4 6
323..................................... 16792 3.2039 1 1 2 4 6
324..................................... 7668 1.9287 1 1 1 2 4
325..................................... 7806 3.8663 1 2 3 5 7
326..................................... 2390 2.7046 1 1 2 3 5
327..................................... 9 3.4444 1 2 3 6 6
328..................................... 691 3.7019 1 2 3 5 7
329..................................... 108 2.4259 1 1 1 3 5
331..................................... 45315 5.5089 1 3 4 7 11
332..................................... 4707 3.4391 1 1 3 4 7
333..................................... 267 4.4082 1 2 3 5 10
334..................................... 14231 4.9975 3 3 4 6 8
335..................................... 10417 3.5491 2 3 3 4 5
336..................................... 46652 3.6099 1 2 3 4 7
337..................................... 31028 2.2136 1 1 2 3 3
338..................................... 2147 5.1202 1 2 3 7 12
339..................................... 1813 4.4865 1 1 3 6 10
340..................................... 2 1.0000 1 1 1 1 1
341..................................... 4093 3.2057 1 1 2 3 6
342..................................... 880 3.4966 1 2 2 4 7
344..................................... 4123 2.3546 1 1 1 2 5
345..................................... 1236 3.7055 1 1 2 4 8
346..................................... 4983 5.7154 1 3 4 7 11
347..................................... 376 3.1303 1 1 2 4 7
348..................................... 3100 4.1839 1 2 3 5 8
349..................................... 600 2.5250 1 1 2 3 5
350..................................... 6571 4.3821 2 2 4 5 8
352..................................... 698 3.9169 1 1 3 5 7
353..................................... 2712 7.0749 3 4 5 8 13
354..................................... 9042 5.7710 3 3 4 6 10
355..................................... 5962 3.4074 2 3 3 4 5
356..................................... 28378 2.5532 1 2 2 3 4
357..................................... 6098 8.6471 3 5 7 10 16
358..................................... 25005 4.4148 2 3 3 5 7
359..................................... 29668 2.8899 2 2 3 3 4
360..................................... 17416 3.0307 1 2 3 3 5
361..................................... 478 3.3703 1 1 2 4 7
362..................................... 1 1.0000 1 1 1 1 1
363..................................... 3606 3.2887 1 2 2 3 7
364..................................... 1831 3.5281 1 1 2 4 7
365..................................... 2018 7.0927 2 3 5 9 15
366..................................... 4378 6.7106 1 3 5 8 14
367..................................... 476 2.9853 1 1 2 3 6
368..................................... 2781 6.2312 2 3 5 8 12
369..................................... 2776 3.2248 1 1 2 4 6
370..................................... 1166 5.9185 3 3 4 5 9
371..................................... 1248 3.6330 2 3 3 4 5
372..................................... 888 3.4651 1 2 2 3 5
373..................................... 3968 2.1467 1 2 2 2 3
374..................................... 140 3.1714 1 2 2 3 4
375..................................... 6 3.8333 1 1 2 5 5
376..................................... 205 3.4439 1 1 2 3 7
377..................................... 35 5.4000 1 1 3 5 13
378..................................... 177 2.7514 1 2 2 3 4
379..................................... 359 3.0836 1 1 2 3 6
380..................................... 91 1.8571 1 1 1 2 3
381..................................... 185 2.3297 1 1 1 3 5
382..................................... 56 1.2857 1 1 1 1 2
383..................................... 1526 4.0216 1 2 3 5 8
384..................................... 123 2.4065 1 1 2 2 5
385..................................... 1 2.0000 2 2 2 2 2
389..................................... 8 6.7500 1 5 5 7 12
[[Page 41619]]
390..................................... 9 3.3333 1 1 4 4 5
392..................................... 2665 9.6432 3 4 7 12 20
394..................................... 1796 6.8135 1 2 4 8 15
395..................................... 77861 4.5487 1 2 3 6 9
396..................................... 17 3.1765 1 1 2 4 6
397..................................... 19299 5.3534 1 2 4 7 11
398..................................... 18648 5.9575 2 3 5 7 11
399..................................... 1513 3.7198 1 2 3 5 7
400..................................... 7367 9.1258 2 3 6 11 20
401..................................... 6271 11.0518 2 5 8 14 22
402..................................... 1464 4.1735 1 1 3 5 9
403..................................... 36557 8.0188 2 3 6 10 16
404..................................... 4130 4.3341 1 2 3 6 9
406..................................... 2851 10.1371 3 5 8 13 21
407..................................... 677 4.1773 1 2 3 5 7
408..................................... 2412 7.7363 1 2 5 10 18
409..................................... 3775 6.1094 2 3 4 6 12
410..................................... 50278 3.5715 1 2 3 4 6
411..................................... 20 2.3500 1 1 2 3 4
412..................................... 28 2.0000 1 1 1 2 4
413..................................... 7463 7.4528 2 3 6 10 15
414..................................... 693 4.1616 1 2 3 5 9
415..................................... 42974 14.0677 4 6 11 17 28
416..................................... 215132 7.3072 2 4 6 9 14
417..................................... 42 4.6905 1 2 3 6 10
418..................................... 22536 6.0572 2 3 5 7 11
419..................................... 15983 4.9037 2 2 4 6 9
420..................................... 3053 3.6495 1 2 3 5 7
421..................................... 13182 3.9219 1 2 3 5 7
422..................................... 93 2.9785 1 1 2 4 6
423..................................... 9177 7.6953 2 3 6 9 16
424..................................... 1398 14.0250 2 5 10 17 27
425..................................... 15651 4.0608 1 2 3 5 8
426..................................... 4620 4.6361 1 2 3 6 9
427..................................... 1678 4.9362 1 2 3 6 11
428..................................... 871 6.8726 1 2 4 8 15
429..................................... 29599 6.5256 2 3 5 8 13
430..................................... 59517 8.3640 2 3 6 11 17
431..................................... 313 7.1374 1 3 5 8 13
432..................................... 442 5.1833 1 2 3 5 10
433..................................... 6368 3.0974 1 1 2 4 6
434..................................... 21885 5.1509 1 2 4 6 10
435..................................... 14675 4.3381 1 2 4 5 8
436..................................... 3324 13.5096 4 7 12 21 27
437..................................... 11674 8.9895 3 5 8 11 15
439..................................... 1202 7.5166 1 3 5 9 15
440..................................... 5340 8.9891 2 3 6 11 19
441..................................... 571 3.0490 1 1 2 4 7
442..................................... 15864 7.8964 1 3 6 10 16
443..................................... 3388 3.2760 1 1 2 4 7
444..................................... 5071 4.2901 1 2 3 5 8
445..................................... 2242 2.9942 1 1 2 4 6
447..................................... 4724 2.5356 1 1 2 3 5
448..................................... 2 1.5000 1 1 2 2 2
449..................................... 26247 3.7078 1 1 3 4 7
450..................................... 6361 2.0483 1 1 1 2 4
451..................................... 4 3.7500 1 1 2 4 8
452..................................... 22505 4.9207 1 2 3 6 10
453..................................... 4265 2.8802 1 1 2 4 5
454..................................... 6006 4.4745 1 2 3 5 9
455..................................... 994 2.5905 1 1 2 3 5
461..................................... 3500 4.5026 1 1 2 5 11
462..................................... 11041 12.2571 4 6 10 16 23
463..................................... 16720 4.2907 1 2 3 5 8
464..................................... 4503 3.1857 1 2 3 4 6
465..................................... 204 3.6029 1 1 1 4 7
466..................................... 1771 4.0011 1 1 2 4 8
467..................................... 1238 3.2504 1 1 2 4 6
468..................................... 58933 13.2171 3 6 10 17 26
471..................................... 11960 5.6279 3 3 5 6 9
[[Page 41620]]
473..................................... 8085 13.1116 2 3 7 19 33
475..................................... 110336 11.1055 2 5 9 15 22
476..................................... 5200 11.6544 2 6 10 15 21
477..................................... 27190 8.0489 1 3 6 10 17
478..................................... 119489 7.2839 1 3 5 9 15
479..................................... 21407 3.7730 1 2 3 5 7
480..................................... 459 23.1046 7 11 16 28 48
481..................................... 274 24.8759 10 19 23 30 40
482..................................... 6476 12.8700 4 7 10 15 23
483..................................... 43362 38.9597 14 21 32 48 71
484..................................... 416 13.1466 1 5 10 18 27
485..................................... 3232 9.1894 4 5 7 11 17
486..................................... 2171 12.1935 1 5 10 16 24
487..................................... 3766 7.3221 1 3 6 9 15
488..................................... 794 18.0416 3 7 13 23 37
489..................................... 14199 8.7326 2 3 6 11 18
490..................................... 4835 5.2709 1 2 4 7 10
491..................................... 11661 3.5467 2 2 3 4 6
492..................................... 2597 16.8063 4 5 11 27 35
493..................................... 55404 5.7170 1 3 5 7 11
494..................................... 26218 2.5095 1 1 2 3 5
495..................................... 143 15.6434 6 8 12 22 29
496..................................... 1111 10.7885 4 5 8 13 21
497..................................... 23280 6.2649 2 3 5 7 11
498..................................... 16782 3.4122 1 2 3 4 6
499..................................... 33561 4.8046 1 2 4 6 9
500..................................... 40918 2.7633 1 1 2 3 5
501..................................... 1994 10.0035 4 5 8 12 19
502..................................... 554 6.2708 3 4 5 7 11
503..................................... 5907 3.9661 1 2 3 5 7
504..................................... 123 31.6260 9 15 26 40 63
505..................................... 158 5.2405 1 1 2 6 13
506..................................... 974 16.7454 4 8 13 22 33
507..................................... 354 9.4831 2 4 8 13 19
508..................................... 602 8.5166 2 3 6 10 17
509..................................... 214 5.2991 1 2 4 7 10
510..................................... 1678 7.3194 2 3 5 9 16
511..................................... 658 5.1884 1 2 3 6 11
----------------
11262262
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) July 1999
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................. 0.379 0.377
ALASKA.............................................. 0.507 0.732
ARIZONA............................................. 0.368 0.532
ARKANSAS............................................ 0.478 0.454
CALIFORNIA.......................................... 0.361 0.457
COLORADO............................................ 0.440 0.571
CONNECTICUT......................................... 0.500 0.506
DELAWARE............................................ 0.495 0.453
DISTRICT OF COLUMBIA................................ 0.519 ........
FLORIDA............................................. 0.372 0.386
GEORGIA............................................. 0.486 0.487
HAWAII.............................................. 0.492 0.556
IDAHO............................................... 0.549 0.576
ILLINOIS............................................ 0.441 0.531
INDIANA............................................. 0.559 0.596
IOWA................................................ 0.498 0.626
KANSAS.............................................. 0.425 0.631
KENTUCKY............................................ 0.483 0.513
LOUISIANA........................................... 0.417 0.489
MAINE............................................... 0.615 0.566
MARYLAND............................................ 0.764 0.821
MASSACHUSETTS....................................... 0.528 0.559
MICHIGAN............................................ 0.474 0.580
MINNESOTA........................................... 0.524 0.594
MISSISSIPPI......................................... 0.469 0.471
MISSOURI............................................ 0.423 0.512
MONTANA............................................. 0.501 0.568
NEBRASKA............................................ 0.488 0.625
NEVADA.............................................. 0.288 0.492
NEW HAMPSHIRE....................................... 0.569 0.592
NEW JERSEY.......................................... 0.412 ........
NEW MEXICO.......................................... 0.476 0.511
NEW YORK............................................ 0.542 0.620
NORTH CAROLINA...................................... 0.537 0.506
NORTH DAKOTA........................................ 0.616 0.662
OHIO................................................ 0.520 0.564
OKLAHOMA............................................ 0.436 0.539
OREGON.............................................. 0.547 0.594
PENNSYLVANIA........................................ 0.403 0.531
PUERTO RICO......................................... 0.488 0.591
RHODE ISLAND........................................ 0.590 ........
SOUTH CAROLINA...................................... 0.453 0.455
SOUTH DAKOTA........................................ 0.522 0.617
TENNESSEE........................................... 0.465 0.490
TEXAS............................................... 0.416 0.519
UTAH................................................ 0.514 0.663
VERMONT............................................. 0.645 0.608
VIRGINIA............................................ 0.472 0.494
WASHINGTON.......................................... 0.590 0.661
WEST VIRGINIA....................................... 0.592 0.571
WISCONSIN........................................... 0.562 0.634
WYOMING............................................. 0.475 0.681
------------------------------------------------------------------------
[[Page 41621]]
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) July 1999
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA....................................................... 0.047
ALASKA........................................................ 0.066
ARIZONA....................................................... 0.042
ARKANSAS...................................................... 0.050
CALIFORNIA.................................................... 0.039
COLORADO...................................................... 0.049
CONNECTICUT................................................... 0.037
DELAWARE...................................................... 0.055
DISTRICT OF COLUMBIA.......................................... 0.039
FLORIDA....................................................... 0.046
GEORGIA....................................................... 0.056
HAWAII........................................................ 0.046
IDAHO......................................................... 0.060
ILLINOIS...................................................... 0.042
INDIANA....................................................... 0.059
IOWA.......................................................... 0.054
KANSAS........................................................ 0.049
KENTUCKY...................................................... 0.050
LOUISIANA..................................................... 0.050
MAINE......................................................... 0.040
MARYLAND...................................................... 0.013
MASSACHUSETTS................................................. 0.056
MICHIGAN...................................................... 0.045
MINNESOTA..................................................... 0.050
MISSISSIPPI................................................... 0.047
MISSOURI...................................................... 0.049
MONTANA....................................................... 0.051
NEBRASKA...................................................... 0.057
NEVADA........................................................ 0.029
NEW HAMPSHIRE................................................. 0.067
NEW JERSEY.................................................... 0.037
NEW MEXICO.................................................... 0.044
NEW YORK...................................................... 0.052
NORTH CAROLINA................................................ 0.050
NORTH DAKOTA.................................................. 0.075
OHIO.......................................................... 0.052
OKLAHOMA...................................................... 0.051
OREGON........................................................ 0.049
PENNSYLVANIA.................................................. 0.042
PUERTO RICO................................................... 0.049
RHODE ISLAND.................................................. 0.035
SOUTH CAROLINA................................................ 0.047
SOUTH DAKOTA.................................................. 0.069
TENNESSEE..................................................... 0.055
TEXAS......................................................... 0.051
UTAH.......................................................... 0.050
VERMONT....................................................... 0.051
VIRGINIA...................................................... 0.060
WASHINGTON.................................................... 0.066
WEST VIRGINIA................................................. 0.056
WISCONSIN..................................................... 0.056
WYOMING....................................................... 0.053
------------------------------------------------------------------------
Table 10.--Percentage Difference in Wage Indexes for Areas That Qualify for a Wage Index Exception for Excluded Hospitals and Units
--------------------------------------------------------------------------------------------------------------------------------------------------------
1982-1996 1984-1996 1988-1996 1990-1996 1991-1996 1992-1996 1993-1996 1994-1996
Area difference difference difference difference difference difference difference difference
--------------------------------------------------------------------------------------------------------------------------------------------------------
Colorado........................................ ........... ........... ........... ........... 10.4524 ........... 8.1881 ...........
Connecticut..................................... 19.6203 21.9951 ........... ........... ........... ........... ........... ...........
Delaware........................................ ........... 10.0096 ........... ........... ........... ........... ........... ...........
Florida......................................... ........... 10.2983 ........... ........... ........... ........... ........... ...........
Georgia......................................... ........... 8.7027 ........... ........... ........... ........... ........... ...........
Hawaii.......................................... ........... 21.3348 11.4158 ........... 12.6562 8.9266 ........... ...........
Illinois........................................ ........... ........... ........... 9.5874 8.7873 ........... ........... ...........
Indiana......................................... ........... ........... ........... 9.2802 ........... ........... ........... ...........
Iowa............................................ ........... ........... ........... 8.2639 9.0834 ........... ........... ...........
Maryland........................................ ........... 8.3480 ........... ........... ........... ........... ........... ...........
Massachusetts................................... 8.6383 12.1756 ........... ........... ........... ........... ........... ...........
Mississippi..................................... ........... ........... ........... 9.6174 9.9473 8.1089 ........... ...........
Nebraska........................................ ........... ........... 14.3694 11.6425 9.9561 10.9156 10.9771 ...........
New Hampshire................................... ........... 11.6434 ........... ........... ........... ........... ........... ...........
New Mexico...................................... ........... ........... ........... 11.9006 ........... ........... ........... ...........
North Carolina.................................. ........... 8.5221 ........... ........... ........... ........... ........... ...........
South Carolina.................................. ........... 14.2383 ........... ........... ........... ........... ........... ...........
South Dakota.................................... ........... ........... ........... 8.9288 9.0543 8.3679 ........... ...........
Tennessee....................................... ........... 8.6185 ........... ........... ........... ........... ........... ...........
Vermont......................................... ........... 11.9881 ........... ........... ........... ........... ........... ...........
Washington...................................... ........... ........... 8.3161 12.0455 8.3048 ........... ........... ...........
Wyoming......................................... ........... ........... ........... 12.9830 11.6587 10.5578 8.3272 ...........
Akron, OH....................................... ........... ........... ........... 9.7516 ........... ........... ........... ...........
Albany, GA...................................... 27.7655 33.1280 28.7328 21.9948 17.5830 20.4926 20.6327 ...........
Anniston, Al.................................... ........... 10.2828 ........... ........... ........... ........... ........... ...........
Arecibo, PR..................................... ........... 10.1831 21.6831 29.8544 26.7773 ........... 9.4816 ...........
Athens, GA...................................... 19.5810 25.7158 18.1110 18.0248 9.5754 ........... ........... ...........
Atlanta, GA..................................... ........... 8.1459 ........... 6.4055 ........... ........... ........... ...........
Atlantic-Cape May, NJ........................... ........... 14.8340 ........... ........... ........... ........... ........... ...........
Bellingham, WA.................................. ........... ........... 8.4523 ........... ........... ........... ........... ...........
Bergen-Passaic, NJ.............................. 12.8013 14.7272 16.7200 ........... ........... ........... ........... ...........
Billings, MT.................................... 16.1065 19.1965 26.2081 30.8632 35.1113 35.3130 29.6247 ...........
Bremerton, WA................................... 13.0957 15.0214 15.3709 15.4435 13.8559 ........... ........... ...........
Brownsville-Harlingen-San Benito, TX............ ........... ........... ........... 8.5425 12.0954 ........... ........... ...........
Bryan-College, Station, TX...................... ........... ........... ........... ........... ........... ........... ........... ...........
Burlington, VT.................................. ........... 12.4268 12.7269 10.3355 ........... 13.9804 ........... ...........
Caquas, PR...................................... ........... 14.7999 ........... ........... ........... ........... ........... ...........
Casper, WY...................................... ........... ........... ........... 9.2907 9.6686 9.1351 ........... ...........
Cedar Rapids, IA................................ ........... ........... ........... 10.3119 ........... ........... ........... ...........
Charlotte-Gastonia-Rock Hill, NC-SC............. ........... 12.6597 ........... ........... ........... ........... ........... ...........
Charlottesville, VA............................. 14.0438 19.5365 9.8608 11.4472 12.9594 15.1868 15.4762 ...........
Chattanooga, TN-GA.............................. ........... 13.4017 ........... ........... 8.8235 ........... 9.9797 ...........
Cheyenne, WY.................................... ........... ........... ........... ........... ........... 8.3488 9.3340 ...........
Clarksville-Hopkinsville, TN-KY................. ........... 11.2945 10.4286 18.4133 ........... ........... ........... ...........
Columbia, SC.................................... ........... 10.8124 ........... ........... ........... ........... ........... ...........
Columbus, GA-AL................................. 8.1734 15.8296 13.6333 12.7302 9.6367 9.7215 9.3830 ...........
Cumberland, MD-MVA.............................. ........... ........... ........... 8.5070 9.0177 ........... ........... ...........
Danville, VA.................................... 12.9378 18.7705 20.6043 14.8561 11.9610 ........... ........... ...........
Decatur, AL..................................... ........... ........... 17.3472 15.8281 8.4468 ........... ........... ...........
Dubuque, IA..................................... ........... ........... ........... ........... 9.1888 ........... ........... ...........
[[Page 41622]]
Duluth-Superior, MN-WI.......................... ........... ........... ........... 10.7902 10.0227 ........... ........... ...........
Dutchess County, NY............................. ........... 8,4704 ........... ........... ........... ........... ........... ...........
Elkhart-Goshen, IN.............................. ........... ........... ........... 9.4527 ........... ........... ........... ...........
Eugene-Springfield, OR.......................... ........... ........... ........... 11.7281 ........... ........... ........... ...........
Flagstaff, AZ-UT................................ ........... ........... ........... ........... ........... ........... ........... ...........
Florence, AL.................................... ........... 11.8054 ........... ........... ........... ........... ........... ...........
Florence, SC.................................... 13.0320 11.8640 ........... ........... ........... ........... ........... ...........
Gadsen, AL...................................... ........... ........... ........... 12.1611 ........... ........... ........... ...........
Gainsville, FL.................................. ........... 15.7424 14.7172 13.7100 14.4832 12.2944 ........... ...........
Grand Junction, CO.............................. ........... ........... ........... ........... ........... ........... ........... ...........
Great Falls, MT................................. ........... ........... ........... 18.0341 21.0392 17.3455 20.4676 ...........
Greeley, CO..................................... ........... ........... ........... 11.4525 ........... ........... ........... ...........
Hickory-Morganton-Lenoir, NC.................... ........... 10.9461 ........... ........... ........... ........... ........... ...........
Houma, LA....................................... ........... ........... 9.0896 ........... ........... ........... ........... ...........
Huntington-Ashland, WV-KY-OH.................... ........... ........... ........... 8.6526 8.6163 8.4473 ........... ...........
Jackson, MS..................................... ........... ........... 8.3592 12.0957 12.2607 11.1892 ........... ...........
Jackson, TN..................................... 9.5132 13.7566 8.6270 ........... ........... ........... ........... ...........
Jacksonville, NC................................ ........... 8.7685 8.6495 8.9799 9.1010 13.3699 11.2812 ...........
Janesville-Beliot, WI........................... ........... ........... 13.9620 14.6249 13.0547 9.9021 11.6946 ...........
Jersey City, NJ................................. ........... 8.7268 10.8011 ........... ........... ........... ........... ...........
Killeen-Temple, TX.............................. 13.1336 ........... ........... ........... ........... ........... ........... ...........
Knoxville, TN................................... ........... 12.1556 ........... ........... ........... 8.5300 8.5044 ...........
Laredo, TX...................................... ........... 13.0842 14.2641 26.7784 19.4632 23.3037 17.6562 ...........
Las Cruse, NM................................... ........... ........... 8.5144 ........... ........... ........... ........... ...........
Lawton, OK...................................... ........... 11.8386 13.5303 12.6581 12.2204 10.9146 13.9374 ...........
Lima, OH........................................ ........... ........... 10.3470 ........... ........... ........... ........... ...........
Lynchburg, VA................................... ........... ........... ........... ........... ........... ........... 8.5602 ...........
Macon, GA....................................... ........... ........... 9.3169 ........... ........... ........... ........... ...........
Mayaguez, PR.................................... ........... ........... ........... ........... ........... ........... 10.8634 ...........
Medford-Ashland, OR............................. ........... 8.6916 ........... 12.5510 8.3660 ........... ........... ...........
Middlesex-Somerset-Hunterdon, NJ................ 8.3277 12.0153 ........... ........... ........... ........... ........... ...........
Monmouth-Ocean, NJ.............................. 14.3408 19.9318 13.6139 9.5243 ........... ........... ........... ...........
Muncie, IN...................................... 8.4919 12.2462 34.1672 26.6394 14.0301 18.7288 11.5183 ...........
Nassau-Suffolk, NY.............................. ........... 16.2468 8.6879 ........... ........... ........... ........... ...........
New Haven-Bridgeport-Stamford-Waterbury-Danbury, 10.4496 14.7474 ........... ........... ........... ........... ........... ...........
CT.............................................
New London-Norwich, CT.......................... 12.8280 16.4870 ........... ........... ........... ........... ........... ...........
New York, NY.................................... ........... 10.1191 ........... ........... ........... ........... ........... ...........
Newburgh, NY-PA................................. 18.2439 22.5618 12.9076 ........... ........... ........... ........... ...........
Ocala, FL....................................... 10.9508 18.0769 11.5170 13.1443 9.4978 ........... ........... ...........
Omaha, NEIA..................................... ........... ........... 16.2054 ........... ........... ........... 10.2732 ...........
Owensboro, KY................................... ........... ........... ........... ........... ........... 8.0822 ........... ...........
Panama City, FL................................. 10.6298 16.0633 ........... 9.5853 21.6370 12.0631 13.7311 ...........
Parkersburg-Marietta, WV-OH..................... ........... ........... ........... 8.4838 ........... 8.5537 ........... ...........
Ponce, PR....................................... ........... ........... ........... ........... 9.0132 ........... ........... ...........
Providence-Warwick-Pawtucket, RI................ ........... 9.8100 ........... ........... ........... ........... ........... ...........
Pueblo, CO...................................... ........... ........... ........... ........... 10.4692 ........... ........... ...........
Redding, CA..................................... ........... 13.7562 ........... ........... ........... ........... ........... ...........
Richland-Kennewick-Pasco, WA.................... 10.3096 15.4733 19.2774 21.6958 16.3350 12.1167 12.5664 ...........
Richmond-Pertersburg, VA........................ ........... ........... ........... 8.3428 ........... ........... ........... ...........
Riverside-San Bernardino, CA.................... ........... ........... ........... ........... ........... ........... ........... ...........
Rochester, MN................................... 12.0161 ........... ........... 13.2930 8.6820 ........... 9.5886 ...........
Salinas, CA..................................... 17.9442 16.9131 12.7030 11.4394 ........... ........... ........... ...........
San Angelo, TX.................................. ........... ........... ........... ........... 9.9972 ........... ........... ...........
Santa Cruz-Watsonville, CA...................... 12.9155 12.9980 8.8387 9.1800 ........... ........... ........... ...........
Santa Fe, NM.................................... ........... 10.0021 14.1030 ........... ........... ........... ........... ...........
Savannah, GA.................................... 12.5014 18.2769 19.4121 14.6131 ........... 10.9835 ........... ...........
Sherman-Denison, TX............................. ........... ........... ........... ........... ........... ........... 8.3004 ...........
Tacoma, WA...................................... ........... 12.0133 11.1455 12.9502 10.2700 ........... ........... ...........
Vallejo-Fairfield-Napa, CA...................... ........... 8.7346 ........... ........... ........... ........... ........... ...........
Wilmington-Newark, DE-MD........................ ........... 9.6799 ........... ........... ........... ........... ........... ...........
Wilmington, NC.................................. ........... 18.6820 11.3188 ........... ........... ........... ........... ...........
Yakima, WA...................................... ........... ........... ........... 9.5536 8.2905 ........... ........... ...........
Yuma, AZ........................................ ........... ........... 11.5934 ........... 14.3977 ........... ........... ...........
--------------------------------------------------------------------------------------------------------------------------------------------------------
Appendix A : Regulatory Impact Analysis
I. Introduction
Section 804(2) of title 5, United States Code (as added by
section 251 of Public Law 104-121), specifies that a ``major rule''
is any rule that the Office of Management and Budget finds is likely
to result in--
An annual effect on the economy of $100 million or
more;
A major increase in costs or prices for consumers,
individual industries, Federal, State, or local government agencies,
or geographic regions; or
Significant adverse effects on competition, employment,
investment productivity, innovation, or on the ability of United
States based enterprises to compete with foreign based enterprises
in domestic and export markets.
We estimate that the impact of this final rule will be to reduce
payments to hospitals by approximately $125 million in FY 2000.
Therefore, this rule is a major rule as defined in Title 5, United
States Code, section 804(2).
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C.
[[Page 41623]]
601 through 612), unless we certify that a final rule will 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 rule that may have a significant
impact on the operations of a substantial number of small rural
hospitals. Such an analysis must conform to the provisions of
section 604 of the RFA. 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 (Public Law 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 made 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 final rule, constitutes a combined regulatory
impact analysis and regulatory flexibility analysis.
In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the Office of Management and Budget.
II. Changes in the Final Rule
Since we published the proposed rule, the market basket
estimates for hospitals subject to the prospective payment system
and hospitals and units excluded from the system have risen by 0.2
and 0.3 percentage points, respectively. As a result, the updates
are 0.2 percent higher than the updates reflected in the impact
analysis for the proposed rule.
Since the May 7, 1999 proposed rule, we have discovered that
incorrect data were used in the capital (and operating) update
framework in estimating the proposed adjustment for the effect of FY
1998 Reclassification and Recalibration. The revised adjustment
resulted in a 0.91 percent increase in the capital rate update
factor in this final rule.
With the exception of these changes, we are generally
implementing the policy and statutory provisions discussed in the
proposed rule.
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 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.
We received no comments on the methodology used for the impact
analysis in the proposed rule.
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 44 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 July 1999, we have
included 4,922 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 July 1999, there were 1,112 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 specialty, there were 586 psychiatric,
200 rehabilitation, 225 long-term care, 71 children's, 20 Christian
Science Sanatoria, and 10 cancer hospitals. In addition, there were
1,497 psychiatric and 942 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 20 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 will be between 0 and 2.9 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 the lesser of 50 percent of
the difference between its reasonable costs and 110 percent of the
limit, or 10 percent of the limit. In no case would the payment
exceed 110 percent of the 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 Policy Changes Under the
Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
In this final rule, we are announcing policy changes and payment
rate updates for the prospective payment systems for operating and
capital-related costs. We have prepared separate impact analyses of
the 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 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 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 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
[[Page 41624]]
not analyzed here. Estimated payment impacts of final FY 2000
changes to the capital prospective payment system are discussed
below in section VII of this Appendix.
The final 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 the floor on the wage index established
by section 4410(a) of the BBA of 1997, which provided that the wage
index for urban hospitals may not be less than the area wage index
applicable to hospitals in rural areas of the State in which the
hospital is located.
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 policy 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 final changes, our
analysis begins with a FY 2000 baseline simulation model using: the
FY 1999 GROUPER (version 16.0); the FY 1999 wage index without
applying the rural floor; and no MGCRB reclassifications. Outlier
payments are set at 5.1 percent of total DRG plus outlier payments.
Each final 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
updating 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 2.9 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 2.9 percent minus 1.8
percentage points (for an update of 1.1 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 6.3 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 final
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, payment adjustments for indirect medical education (IME)
and disproportionate share (DSH) are lower in FY 2000 relative to FY
1999. 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 4,922 hospitals included in the analysis. This figure
represents 53 fewer hospitals than were included in the impact
analysis in the FY 1999 final rule (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 2,782
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,584 hospitals located in large
urban areas (populations over 1 million), and 1,198 hospitals in
other urban areas (populations of 1 million or fewer). In addition,
there are 2,140 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 2,858,
1,662, 1,197, and 2,064, respectively.
The next three groupings examine the impacts of the final
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 3,809 nonteaching hospitals in our analysis, 871 teaching
hospitals with fewer than 100 residents, and 242 teaching hospitals
with 100 or more residents.
In the DSH categories, hospitals are grouped according to their
DSH payment status, and whether they are considered urban or rural
after MGCRB reclassifications. Hospitals in the rural DSH
categories, therefore, represent hospitals that were not
reclassified for purposes of the standardized amount 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 final 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 (154), SCHs (647), MDHs
(355), and SCH and RRCs (57) shown here were not reclassified for
purposes of the standardized amount. There are 15 RRCs, 3 SCHs, and
2 SCH and RRCs that will be reclassified for the standardized amount
in FY 2000 that, therefore, are not included in these rows.
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 some hospitals (80 and
82, respectively). 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.
[[Page 41625]]
Table I--Impact Analysis of Changes For FY 2000 Operating Prospective Payment System
[PERCENT CHANGES IN PAYMENTS PER CASE]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Remove GME Blended All FY
Number of DRG Wage index New wage and CRNA wage index DRG & WI MGCRB 2000
hospitals\1\ recalib.\2\ floor \3\ data \4\ costs \5\ costs \6\ changes reclassification changes
(0) (1) (2) (3) (4) (5) (6) (7) (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION)
ALL HOSPITALS................... 4,922 0.0 0.1 0.1 0.4 0.1 0.0 0.0 -0.5
URBAN HOSPITALS................. 2,782 0.0 0.1 0.0 0.3 0.1 -0.1 -0.4 -0.7
LARGE URBAN................. 1,584 0.0 0.0 0.0 0.1 0.0 -0.1 -0.4 -0.8
OTHER URBAN................. 1,198 0.0 0.2 0.0 0.6 0.1 0.1 -0.4 -0.5
RURAL HOSPITALS................. 2,140 0.2 0.0 0.4 0.6 0.5 0.5 2.6 1.0
BED SIZE (URBAN):
0-99 BEDS................... 727 0.1 0.3 -0.2 0.4 -0.2 0.1 -0.5 -0.2
100-199 BEDS................ 938 0.1 0.2 0.1 0.4 0.1 0.2 -0.5 -0.1
200-299 BEDS................ 553 0.0 0.1 0.1 0.4 0.1 0.0 -0.4 -0.5
300-499 BEDS................ 422 0.0 0.1 0.0 0.4 0.1 -0.1 -0.3 -0.7
500 OR MORE BEDS............ 142 -0.1 0.0 0.0 0.0 0.0 -0.2 -0.4 -1.6
BED SIZE (RURAL):
0-49 BEDS................... 1,194 0.3 0.0 0.4 0.5 0.5 0.6 0.2 1.4
50-99 BEDS.................. 571 0.2 0.0 0.4 0.5 0.5 0.5 1.0 1.2
100-149 BEDS................ 223 0.2 0.0 0.4 0.7 0.5 0.5 3.8 1.2
150-199 BEDS................ 87 0.1 0.0 0.5 0.6 0.6 0.5 4.5 1.2
200 OR MORE BEDS............ 65 0.1 0.0 0.4 0.5 0.5 0.4 4.8 0.3
URBAN BY CENSUS DIVISION:
NEW ENGLAND................. 149 0.0 0.2 0.6 0.8 0.7 0.6 -0.2 -0.2
MIDDLE ATLANTIC............. 421 0.0 0.1 -0.2 -0.5 -0.2 -0.3 -0.3 -1.4
SOUTH ATLANTIC.............. 407 0.0 0.2 0.1 0.9 0.3 0.2 -0.4 -0.2
EAST NORTH CENTRAL.......... 467 0.0 0.1 0.4 0.0 0.4 0.3 -0.4 -0.4
EAST SOUTH CENTRAL.......... 165 0.0 0.1 0.5 0.3 0.6 0.4 -0.4 0.0
WEST NORTH CENTRAL.......... 190 -0.1 0.0 -0.1 0.1 0.0 -0.3 -0.5 -0.8
WEST SOUTH CENTRAL.......... 353 0.0 0.0 -0.6 0.4 -0.5 -0.7 -0.5 -1.1
MOUNTAIN.................... 134 -0.1 0.0 -0.1 0.2 0.0 -0.3 -0.5 -0.5
PACIFIC..................... 449 0.0 0.1 -0.3 0.9 -0.2 -0.3 -0.4 -0.8
PUERTO RICO................. 47 0.1 0.0 0.4 0.3 0.4 0.4 -0.5 0.2
RURAL BY CENSUS DIVISION:
NEW ENGLAND................. 52 0.1 0.0 -0.2 0.1 -0.1 -0.3 2.5 0.5
MIDDLE ATLANTIC............. 79 0.1 0.0 -0.4 0.0 -0.4 -0.4 2.2 0.7
SOUTH ATLANTIC.............. 280 0.2 0.0 1.0 0.7 1.1 1.1 3.0 0.9
EAST NORTH CENTRAL.......... 283 0.1 0.0 0.3 0.6 0.4 0.3 2.3 1.0
EAST SOUTH CENTRAL.......... 267 0.3 0.0 0.7 0.8 0.8 0.9 2.7 1.6
WEST NORTH CENTRAL.......... 492 0.1 0.0 0.8 0.4 0.9 0.8 2.3 1.5
WEST SOUTH CENTRAL.......... 341 0.3 0.0 -0.3 0.7 -0.2 -0.1 3.5 0.9
MOUNTAIN.................... 201 0.2 0.0 0.5 0.4 0.5 0.5 1.8 1.3
PACIFIC..................... 140 0.1 0.0 -0.4 0.7 -0.2 -0.3 1.9 0.0
PUERTO RICO................. 5 0.1 0.0 1.8 0.6 1.9 1.9 1.6 2.4
(BY PAYMENT CATEGORIES)
URBAN HOSPITALS................. 2,858 0.0 0.1 0.0 0.3 0.1 0.0 -0.3 -0.7
LARGE URBAN................. 1,662 0.0 0.0 0.0 0.1 0.0 -0.1 -0.3 -0.9
OTHER URBAN................. 1,197 0.0 0.2 0.1 0.6 0.2 0.1 -0.3 -0.4
RURAL HOSPITALS................. 2,064 0.2 0.0 0.4 0.6 0.5 0.5 2.3 1.1
TEACHING STATUS:
NON-TEACHING................ 3,809 0.1 0.1 0.1 0.5 0.2 0.2 0.3 0.2
LESS THAN 100 RESIDENTS..... 871 0.0 0.1 0.0 0.4 0.1 -0.1 -0.3 -0.6
100+ RESIDENTS.............. 242 0.0 0.0 0.1 -0.1 0.1 -0.1 -0.2 -1.5
DISPROPORTIONATE SHARE HOSPITALS
(DSH):
NON-DSH..................... 3,069 0.0 0.1 0.1 0.4 0.1 0.0 0.3 -0.2
URBAN DSH 100 BEDS OR MORE.. 1,387 0.0 0.1 0.0 0.3 0.1 0.0 -0.4 -0.8
FEWER THAN 100 BEDS......... 89 0.2 0.1 -0.2 0.6 0.0 0.1 -0.5 0.1
RURAL DSH SOLE COMMUNITY 158 0.3 0.0 0.4 0.6 0.6 0.6 0.3 2.1
(SCH)......................
REFERRAL CENTERS (RRC)...... 60 0.2 0.0 0.7 0.7 0.8 0.8 5.0 1.2
OTHER RURAL DSH HOSPITALS 49 0.2 0.0 0.7 0.8 0.8 0.9 1.0 1.1
100 BEDS OR MORE...........
FEWER THAN 100 BEDS......... 110 0.4 0.0 0.7 0.8 0.9 1.0 0.2 2.0
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH....... 716 0.0 0.0 0.0 0.2 0.1 -0.1 -0.4 -1.1
TEACHING AND NO DSH......... 331 -0.1 0.1 0.0 0.2 0.1 -0.2 -0.1 -0.8
NO TEACHING AND DSH......... 760 0.1 0.2 0.0 0.6 0.1 0.1 -0.2 0.0
NO TEACHING AND NO DSH...... 1,052 0.0 0.2 0.0 0.4 0.1 0.1 -0.4 -0.3
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS HOSPITALS. 851 0.3 0.0 0.5 0.7 0.7 0.7 1.1 1.2
RRC......................... 154 0.1 0.0 0.4 0.7 0.6 0.4 5.7 0.6
SCH......................... 647 0.2 0.0 0.2 0.3 0.3 0.3 0.3 1.4
MDH......................... 355 0.3 0.0 0.4 0.5 0.5 0.6 0.3 1.2
SCH AND RRC................. 57 0.1 0.0 0.2 0.3 0.2 0.1 2.2 1.4
TYPE OF OWNERSHIP:
VOLUNTARY................... 2,831 0.0 0.1 0.1 0.3 0.1 0.0 -0.1 -0.5
PROPRIETARY................. 752 0.1 0.1 0.0 0.6 0.1 0.0 0.0 -0.2
GOVERNMENT.................. 1,259 0.1 0.1 0.2 0.6 0.3 0.2 0.3 -0.3
UNKNOWN..................... 80 0.0 0.0 0.3 -0.8 0.1 0.0 -0.5 -1.4
[[Page 41626]]
MEDICARE UTILIZATION AS A
PERCENT OF INPATIENT DAYS:
0-25........................ 386 0.1 0.0 -0.3 0.6 -0.1 -0.3 -0.1 -1.3
25-50....................... 1,775 0.0 0.0 0.0 0.3 0.1 -0.1 -0.3 -0.8
50-65....................... 1,893 0.0 0.1 0.1 0.4 0.2 0.1 0.2 -0.1
OVER 65..................... 786 0.1 0.2 0.3 0.4 0.3 0.4 0.3 0.1
UNKNOWN..................... 82 0.0 0.0 0.3 -0.8 0.1 0.0 -0.5 -1.4
HOSPITALS RECLASSIFIED BY THE
MEDICARE GEOGRAPHIC REVIEW BOARD
RECLASSIFICATION STATUS DURING
FY 1999 AND FY 2000:
RECLASSIFIED DURING BOTH FY 370 0.1 0.0 0.3 0.7 0.4 0.3 5.9 0.0
1999 AND FY 2000...........
URBAN................... 57 0.0 0.0 0.0 0.9 0.1 0.0 4.4 -1.4
RURAL................... 313 0.1 0.0 0.4 0.6 0.5 0.4 6.6 0.7
RECLASSIFIED DURING FY 2000 127 0.1 0.0 0.2 0.5 0.3 0.2 4.4 4.7
ONLY.......................
URBAN................... 26 0.0 0.1 -0.1 0.4 0.0 -0.2 3.3 2.7
RURAL................... 101 0.2 0.0 0.6 0.6 0.7 0.7 5.7 7.0
RECLASSIFIED DURING FY 1999 188 0.1 1.1 -0.2 0.6 -0.1 0.8 -0.5 -3.9
ONLY.......................
URBAN................... 100 0.0 1.7 -0.6 0.6 -0.4 1.0 -0.5 -3.7
RURAL................... 88 0.2 0.0 0.4 0.6 0.5 0.5 -0.5 -4.2
FY 2000 RECLASSIFICATIONS:
ALL RECLASSIFIED HOSPITALS.. 498 0.1 0.0 0.3 0.6 0.4 0.3 5.6 0.9
STANDARDIZED AMOUNT ONLY 66 0.2 0.0 0.3 0.8 0.4 0.4 2.6 -1.4
WAGE INDEX ONLY......... 386 0.1 0.0 0.3 0.6 0.4 0.3 6.0 1.3
BOTH.................... 46 0.1 0.0 -0.1 0.7 0.0 -0.1 4.8 -0.5
NONRECLASSIFIED......... 4,398 0.0 0.1 0.1 0.3 0.1 0.0 -0.6 -0.6
ALL URBAN RECLASSIFIED...... 83 0.0 0.0 -0.1 0.7 0.1 -0.1 4.1 -0.2
STANDARDIZED AMOUNT ONLY 13 0.1 0.1 -0.4 0.9 -0.2 -0.2 0.8 -4.4
WAGE INDEX ONLY............. 47 0.0 0.1 0.2 0.7 0.3 0.1 5.4 0.6
BOTH........................ 23 0.2 0.0 -0.8 0.7 -0.6 -0.7 0.7 -1.1
NONRECLASSIFIED............. 2,673 0.0 0.1 0.0 0.3 0.1 -0.1 -0.6 -0.7
ALL RURAL RECLASSIFIED.......... 416 0.1 0.0 0.5 0.6 0.6 0.5 6.5 1.5
STANDARDIZED AMOUNT ONLY.... 53 0.2 0.0 0.7 0.8 0.9 0.9 3.9 0.6
WAGE INDEX ONLY............. 339 0.1 0.0 0.4 0.6 0.5 0.4 6.3 1.7
BOTH........................ 23 0.1 0.0 1.0 0.6 1.1 1.0 11.6 0.5
NONRECLASSIFIED............. 1,725 0.2 0.0 0.4 0.5 0.5 0.5 -0.4 0.6
OTHER RECLASSIFIED HOSPITALS 26 0.1 8.7 -0.4 0.3 -0.3 8.3 1.5 3.2
(SECTION 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 impacts of implementing the rural wage index floor for urban hospitals in an area that otherwise would have a wage index below
the Statewide rural wage index. This was established by section 4410(a) of the BBA of 1997.
\4\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1996 cost reports.
\5\ 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.
\6\ 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 based on a blend of 20 percent of an average hourly wage after removing these costs and 80 percent of an average hourly
wage without removing these costs.
\7\ This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate
the wage index, and the budget neutrality adjustment factor for these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of
the Act. Thus, it represents the combined impacts shown in columns 1, 2, 3, 4, and 5, and the FY 2000 budget neutrality factor of 0.997808.
\8\ 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.
\9\ This column shows changes in payments from FY 1999 to FY 2000. It incorporates all of the changes displayed in columns 6 and 7 (the changes
displayed in columns 1, 2 and 5 are included in column 6). 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.
B. Impact of the 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 final 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 FY 2000
DRG relative weights (GROUPER version 17). Overall payments per case
are unchanged due to the DRG reclassifications and recalibration.
Consistent with the minor
[[Page 41627]]
changes we made in the FY 2000 GROUPER, the redistributional impacts
of DRG reclassifications and recalibration across hospital groups
are very small (no change 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 0.1 percent increase for hospitals with fewer
than 200 beds), and small decreases for larger hospitals (a 0.1
percent decrease for hospitals with more than 500 beds). Among rural
hospitals, small hospital categories experience the largest
increases, a 0.3 percent increase for hospitals with fewer than 50
beds.
The breakdown by urban census division shows either no impact or
a small decrease (0.1 percent), except that payments to urban
hospitals in Puerto Rico increase by 0.1 percent. All rural hospital
census divisions experience payment increases, which range from 0.1
percent to 0.3 percent for hospitals in the East South Central and
West South Central census divisions.
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 5.7715 in this final rule for FY 2000. Also, the relative
weight for DRG 112 (Percutaneous Cardiovascular Procedures) declined
from 1.9893 in FY 1999 to 1.9217 in this final 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 the Wage Index Floor for Urban Areas (Column 2)
Section 4410(a) of the BBA of 1997 required that the wage
indexes for urban hospitals may not be below the Statewide rural
wage index for the State in which the urban hospitals are located.
The section went on to state that this floor must be implemented in
a budget neutral manner, so that total payments after establishing
the floor are equal to what they were prior to establishing the
floor. We include this impact when we calculate the wage and
recalibration budget neutrality factor, as noted in the Addendum to
this final rule.
There are 36 MSAs (and 226 hospitals) affected by this provision
for FY 2000. The MSAs affected are identified in Table 4A, as
indicated in the footnote. The largest impacts among census
divisions are increases of 0.2 percent for urban hospitals in New
England and the South Atlantic. In New England, several
Massachusetts MSAs (including the 63 hospitals in the Boston MSA)
receive the rural Massachusetts wage index. Similarly, in the South
Atlantic, seven Florida MSAs receive the rural Florida wage index.
D. Impact of Updating the Wage Data (Column 3)
Section 1886(d)(3)(E) of the Act requires that, beginning
October 1, 1993, we annually update the wage data used to calculate
the wage index. In accordance with this requirement, the 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 3 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 including the application of the rural floor 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 are 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 0.1 percent increase in hospital payments (prior to
applying the budget neutrality factor, see column 6). Rural
hospitals especially appear to benefit from the update. Their
payments increase by 0.4 percent. Rural Arizona experiences an
increase of nearly 7 percent in the prereclassification wage index
values due to new data.
Urban hospitals as a group are not significantly affected by the
updated wage data. Urban West South Central hospitals experience a
0.6 percent decrease. Meanwhile, the urban New England census
division experiences a 0.6 percent increase, and urban East South
Central payments per case increase 0.5 percent due to the update to
the wage data.
The largest increases are seen in the rural census divisions.
Rural Puerto Rico experiences the greatest positive impact, 1.8
percent. Hospitals in three other rural census divisions receive
relatively large positive impacts: South Atlantic at 1.0 percent,
East South Central at 0.7 percent, and West North Central at 0.8
percent.
E. Impact of Removing Teaching Physicians' Part A, Residents', and
CRNAs' Costs (Column 4)
As discussed in section III.C of the preamble, we are revising
the calculation of the wage index by phasing out the costs and hours
associated with teaching physicians Part A, residents, and CRNAs.
Although the 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 the
hospital industry (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 4 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 0.4 percent increase in total payments (prior
to applying budget neutrality). The FY 2000 wage index is, however,
based on a blended average hourly wage. The impacts of this blended
approach are shown in column 5.
The impacts of removing these costs from the wage index
calculation are generally positive across the majority of hospital
categories, with negative impacts concentrated in particular groups.
Examining the impacts across urban and rural census divisions
indicate that urban Middle Atlantic hospitals experience a 0.5
percent decrease. This effect is attributable to the concentration
of teaching hospitals in this census division. The largest positive
impacts occur in the urban South Atlantic and the Pacific census
divisions, with 0.9 percent payment increases.
F. Impact of 5-Year Phase-Out of Teaching Physicians', Residents',
and CRNAs' Costs (Column 5)
As described above in section III.E of this final rule, the 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 Part A teaching physicians, residents, or CRNAs. As
expected, the hospital categories experiencing significant payment
impacts in column 4 are mitigated
[[Page 41628]]
considerably by the blend. The impact is 0.1 percent for all
hospitals and for urban hospitals as a category, while for rural
hospitals it is 0.5 percent.
The impacts in this column illustrate that, for the FY 2000 wage
index, replacing hospitals' FY 1995 wage data with FY 1996 wage data
has a much greater impact on the final wage indexes than the removal
of GME and CRNA costs. The urban West South Central census division
loses 0.6 percent from the new wage data, and gains 0.4 percent from
the removal of GME and CRNA costs, but the impact of the blended
wage index is a 0.5 decrease relative to last year's wage index.
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 changes for the FY 2000 wage index
relative to the FY 1999 wage index. The majority of labor market
areas (318) experience less than a 5-percent change. A total of 30
labor market areas experience an increase of more than 5 percent,
with 8 having an increase greater than 10 percent. A total of 22
areas experience decreases of more than 5 percent. Of those, 5
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 8
Increase more than 5 percent and less 29 22
than 10 percent........................
Increase or decrease less than 5 percent 305 318
Decrease more than 5 percent and less 28 17
than 10 percent........................
Decrease more than 10 percent........... 0 5
------------------------------------------------------------------------
Among urban hospitals, 112 would experience an increase of
between 5 and 10 percent and 21 more than 10 percent. A total of 13
rural hospitals have increases greater than 5 percent, but none
greater than 10 percent. On the negative side, 121 urban hospitals
but no rural hospitals have decreases in their wage index values of
at least 5 percent but less than 10 percent. There also are no rural
hospitals with decreases greater than 10 percent. However, there are
18 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................. 21 0
Increase more than 5 percent and less than 10 112 13
percent......................................
Increase or decrease less than 5 percent...... 2587 2051
Decrease more than 5 percent and less than 10 121 0
percent......................................
Decrease more than 10 percent................. 18 0
------------------------------------------------------------------------
G. Combined Impact of DRG and Wage Index Changes--Including Budget
Neutrality Adjustment (Column 6)
The impact of DRG reclassifications and recalibration on
aggregate payments is required by section 1886(d)(4)(C)(iii) of the
Act to be budget neutral. In addition, section 1886(d)(3)(E) of the
Act specifies that any updates or adjustments to the wage index are
to be budget neutral. As noted in the Addendum to this final rule,
we compared simulated aggregate payments using the FY 1999 DRG
relative weights and wage index (prior to application of the rural
floor) to simulated aggregate payments using the FY 2000 DRG
relative weights and blended wage index, after applying the rural
floor. Based on this comparison, we computed a wage and
recalibration budget neutrality factor of 0.997808. In Table I, the
combined overall impacts of the effects of both the DRG
reclassifications and recalibration and the updated wage index are
shown in column 6. The 0.0 percent impact for All Hospitals
demonstrates that these changes, in combination with the budget
neutrality factor, are budget neutral.
For the most part, the changes in this column are the sum of the
changes in columns 1, 2, and 5, minus approximately 0.2 percent
attributable to the budget neutrality factor. There may be some
variation of plus or minus 0.1 percent due to rounding.
H. Impact of MGCRB Reclassifications (Column 7)
Our impact analysis to this point has assumed hospitals are paid
on the basis of their actual geographic location (with the exception
of ongoing policies that provide that certain hospitals receive
payments on bases other than where they are geographically located,
such as hospitals in rural counties that are deemed urban under
section 1886(d)(8)(B) of the Act). The changes in column 7 reflect
the per case payment impact of moving from this baseline to a
simulation incorporating the MGCRB decisions for FY 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 through 2001, for purposes of qualifying for a DSH
adjustment or to receive a higher DSH payment.
The 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. Additional changes that resulted from
the Administrator's review of MGCRB decisions or a request by a
hospital to withdraw its application are reflected in this final
rule.
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 0.993799 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4.b. of the
Addendum to this final rule.)
As a group, rural hospitals benefit from geographic
reclassification. Their payments rise 2.6 percent, while payments to
urban hospitals decline 0.4 percent. Among urban hospital groups
(that is, bed size, census division, and special payment status),
payments generally decline.
A positive impact is evident among all rural hospital groups.
The smallest increases among the rural census divisions is 1.6
percent for Puerto Rico and 1.8 percent for Mountain. The largest
increase is in rural West South Central, with an increase of 3.5
percent.
Among rural hospitals designated as RRCs, 128 hospitals are
reclassified for purposes of the wage index only, leading to the 5.7
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 4.8 percent increase in payments.
[[Page 41629]]
Rural hospitals reclassified for FY 1999 and FY 2000 experience
a 6.6 percent increase in payments. This may be due to the fact that
these hospitals have the most to gain from reclassification and have
been reclassified for a period of years. Rural hospitals
reclassified for FY 2000 but not FY 1999 experience a 5.7 percent
increase in payments, while rural hospitals reclassified for FY 1999
but not FY 2000 experience a 0.5 percent decrease in payments. Urban
hospitals reclassified for FY 1999 but not FY 2000 experience a 0.5
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 an 11.6 percent increase in payments. In addition, rural
hospitals reclassified just for the wage index receive a 6.3 percent
payment increase. The overall impact on reclassified hospitals is to
increase their payments per case by an average of 5.6 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 0.6 percent. Rural
nonreclassified hospitals decrease by 0.4 percent, and urban
nonreclassified hospitals lose 0.6 percent (the amount of the budget
neutrality offset).
I. All Changes (Column 8)
Column 8 compares our estimate of payments per case,
incorporating all changes reflected in this final rule for FY 2000
(including statutory changes), to our estimate of payments per case
in FY 1999. It includes the effects of the 1.1 percent update to the
standardized amounts and the hospital-specific rates for SCHs and
MDHs. It also reflects the 1.2 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 (6.3 percent), as described in the
introduction to this Appendix and the Addendum to this final 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 BBA 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 have received. 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 7 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 2.6
percent increase in column 7 for FY 2000. Therefore, the net change
in FY 2000 payments due to reclassification for rural hospitals is
actually a decrease of 0.1 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 8 may not equal the
sum of the changes in columns 6 and 7, 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 0.5 percent decrease. This reflects the 1.1 percent
update for FY 2000, the 1.2 percent lower outlier payments in FY
2000 compared to FY 1999 (5.1 percent compared to 6.3 percent); and
the 0.5 percent reduction due to lower IME and DSH payments.
Hospitals in urban areas experience a 0.7 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 0.8 percent per case
compared to 0.5 percent per case for hospitals in other urban areas.
Hospitals in rural areas, meanwhile, experience a 1.0 percent
payment increase. As discussed above, this is primarily due to the
positive effect of the wage index and DRG changes (0.5 percent
increase).
Among census divisions, urban Middle Atlantic displays the
largest negative impact (-1.4 percent), followed by the West South
Central (-1.1 percent decrease in payments). In the case of
hospitals in the urban Middle Atlantic census division, these
decreases are related to changes to the wage index, plus a greater
impact of the IME and DSH payment reductions and the decline in
estimated outlier payments. In the case of the urban West South
Central census division, the decline is largely related to changes
in the wage index. East South Central and Puerto Rico are the only
urban categories grouped by census division not exhibiting decreases
in payments per case for FY 2000.
No rural census division experiences a negative payment impact,
although payments to rural hospitals in the Pacific census division
are unchanged from FY 1999. The largest increases by rural hospitals
are in Puerto Rico at 2.4 percent. Among rural census divisions, the
largest increases are in the East South Central and West North
Central, with 1.6 percent and 1.5 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 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 3.0 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 1.4 percent, 1.2
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 6.3 of total DRG plus outlier payments to the projected 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 3.9 percent.
The urban hospitals in this category lose 3.7 percent, while the
rural hospitals lose 4.2 percent. On the other hand, hospitals
reclassified for FY 2000 that were not reclassified for FY 1999
would experience the greatest payment increases: 4.7 percent
overall; 7.0 percent for 101 rural hospitals in this category and
2.7 percent for 26 urban hospitals.
[[Page 41630]]
Table II.--Impact Analysis of Changes For FY 2000 Operating Prospective Payment System
[Payments per case]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY
Number of 1999 2000
hospitals payment per payment per All changes
case case
(1) (2) \1\ (3) \1\ (4)
----------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION)
ALL HOSPITALS............................................... 4,922 6,779 6,747 -0.5
URBAN HOSPITALS......................................... 2,782 7,344 7,293 -0.7
LARGE URBAN AREAS....................................... 1,584 7,881 7,815 -0.8
OTHER URBAN AREAS........................................... 1,198 6,620 6,590 -0.5
RURAL HOSPITALS............................................. 2,140 4,493 4,540 1.0
BED SIZE (URBAN):
0-99 BEDS............................................. 727 4,969 4,958 -0.2
100-199 BEDS............................................ 938 6,150 6,141 -0.1
200-299 BEDS............................................ 553 7,012 6,977 -0.5
300-499 BEDS............................................ 422 7,819 7,764 -0.7
500 OR MORE BEDS........................................ 142 9,882 9,726 -1.6
BED SIZE (RURAL):
0-49 BEDS............................................. 1,194 3,720 3,771 1.4
50-99 BEDS............................................. 570 4,225 4,274 1.2
100-149 BEDS............................................ 223 4,584 4,638 1.2
150-199 BEDS............................................ 87 4,962 5,019 1.2
200 OR MORE BEDS........................................ 65 5,734 5,749 0.3
URBAN BY CENSUS DIVISION:
NEW ENGLAND............................................. 149 7,757 7,739 -0.2
MIDDLE ATLANTIC......................................... 421 8,278 8,162 -1.4
SOUTH ATLANTIC.......................................... 407 6,970 6,954 -0.2
EAST NORTH CENTRAL...................................... 467 6,991 6,960 -0.4
EAST SOUTH CENTRAL...................................... 165 6,574 6,572 0.0
WEST NORTH CENTRAL...................................... 190 7,099 7,043 -0.8
WEST SOUTH CENTRAL...................................... 353 6,785 6,709 -1.1
MOUNTAIN................................................ 134 7,014 6,983 -0.5
PACIFIC................................................. 449 8,451 8,382 -0.8
PUERTO RICO............................................. 47 3,115 3,120 0.2
RURAL BY CENSUS DIVISION:
NEW ENGLAND............................................. 52 5,354 5,383 0.5
MIDDLE ATLANTIC......................................... 79 4,858 4,892 0.7
SOUTH ATLANTIC.......................................... 280 4,660 4,702 0.9
EAST NORTH CENTRAL...................................... 283 4,562 4,608 1.0
EAST SOUTH CENTRAL...................................... 267 4,138 4,203 1.6
WEST NORTH CENTRAL...................................... 492 4,282 4,348 1.5
WEST SOUTH CENTRAL...................................... 341 3,997 4,031 0.9
MOUNTAIN................................................ 201 4,763 4,825 1.3
PACIFIC................................................. 140 5,566 5,567 0.0
PUERTO RICO............................................. 5 2,327 2,383 2.4
(BY PAYMENT CATEGORIES)
URBAN HOSPITALS............................................. 2,858 7,309 7,259 -0.7
LARGE URBAN............................................. 1,662 7,807 7,740 -0.9
OTHER URBAN............................................. 1,197 6,609 6,582 -0.4
RURAL HOSPITALS............................................. 2,064 4,468 4,516 1.1
TEACHING STATUS:
NON-TEACHING............................................ 3,809 5,462 5,471 0.2
FEWER THAN 100 RESIDENTS................................ 871 7,173 7,130 -0.6
100 OR MORE RESIDENTS................................... 242 10,898 10,737 -1.5
DISPROPORTIONATE SHARE HOSPITALS (DSH):
NON-DSH................................................. 3,069 5,800 5,787 -0.2
URBAN DSH:
100 BEDS OR MORE.................................... 1,387 7,959 7,899 -0.8
FEWER THAN 100 BEDS................................. 89 5,099 5,105 0.1
RURAL DSH:
SOLE COMMUNITY (SCH)................................ 158 4,190 4,277 2.1
REFERRAL CENTERS (RRC).............................. 60 5,310 5,371 1.2
OTHER RURAL DSH HOSPITALS:
100 BEDS OR MORE.................................... 49 4,051 4,094 1.1
FEWER THAN 100 BEDS................................. 110 3,589 3,660 2.0
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH................................... 716 8,922 8,827 -1.1
TEACHING AND NO DSH..................................... 331 7,318 7,256 -0.8
NO TEACHING AND DSH..................................... 760 6,331 6,329 0.0
NO TEACHING AND NO DSH.................................. 1,052 5,641 5,624 -0.3
[[Page 41631]]
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS HOSPITALS............................. 851 3,911 3,956 1.2
RRC..................................................... 154 5,198 5,230 0.6
SCH..................................................... 647 4,462 4,523 1.4
MDH..................................................... 355 3,758 3,803 1.2
SCH AND RRC............................................. 57 5,374 5,446 1.4
TYPE OF OWNERSHIP:
VOLUNTARY............................................... 2,831 6,957 6,920 -0.5
PROPRIETARY............................................. 752 6,187 6,171 -0.2
GOVERNMENT.............................................. 1,259 6,295 6,279 -0.3
UNKNOWN................................................. 80 9,713 9,575 -1.4
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT DAYS:
0-25................................................... 386 8,790 8,678 -1.3
25-50................................................... 1,775 7,908 7,845 -0.8
50-65................................................... 1,893 5,998 5,992 -0.1
OVER 65................................................. 786 5,273 5,276 0.1
UNKNOWN................................................. 82 9,711 9,573 -1.4
HOSPITALS RECLASSIFIED BY THE MEDICARE GEOGRAPHIC REVIEW
BOARD
RECLASSIFICATION STATUS DURING FY 1999 AND FY 2000:
RECLASSIFIED DURING BOTH FY 1999 AND FY 2000............ 370 5,823 5,826 0.0
URBAN............................................... 57 7,961 7,853 -1.4
RURAL............................................... 313 5,185 5,220 0.7
RECLASSIFIED DURING FY 2000 ONLY........................ 127 5,580 5,840 4.7
URBAN............................................... 26 7,182 7,377 2.7
RURAL............................................... 101 4,385 4,693 7.0
RECLASSIFIED DURING FY 1999 ONLY........................ 188 5,597 5,378 -3.9
URBAN............................................... 100 6,389 6,151 -3.7
RURAL............................................... 88 4,574 4,382 -4.2
FY 2000 RECLASSIFICATIONS:
ALL RECLASSIFIED HOSPITALS.............................. 498 5,776 5,828 0.9
STANDARDIZED AMOUNT ONLY................................ 66 4,768 4,701 -1.4
WAGE INDEX ONLY......................................... 386 5,822 5,900 1.3
BOTH.................................................... 46 6,255 6,223 -0.5
NONRECLASSIFIED......................................... 4,398 6,910 6,867 -0.6
ALL URBAN RECLASSIFIED...................................... 83 7,717 7,704 -0.2
STANDARDIZED AMOUNT ONLY................................ 13 5,279 5,047 -4.4
WAGE INDEX ONLY......................................... 47 8,415 8,464 0.6
BOTH.................................................... 23 6,992 6,912 -1.1
NONRECLASSIFIED......................................... 2,673 7,342 7,289 -0.7
ALL RURAL RECLASSIFIED...................................... 416 5,062 5,139 1.5
STANDARDIZED AMOUNT ONLY................................ 53 4,473 4,501 0.6
WAGE INDEX ONLY......................................... 339 5,089 5,175 1.7
BOTH.................................................... 23 5,384 5,409 0.5
NONRECLASSIFIED......................................... 1,725 4,113 4,140 0.6
OTHER RECLASSIFIED HOSPITALS (SECTION 1886(d)(8)(B))........ 26 4,663 4,813 3.2
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.
Table II presents the projected impact of the 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 8 of Table I.
VII. Impact of Changes in the Capital Prospective Payment System
A. General Considerations
We now have cost report data for the 6th year of the capital
prospective payment system (cost reports beginning in FY 1997)
available through the March 1999 update of the Health Care Provider
Cost Report Information System (HCRIS). We also have updated
information on the projected aggregate amount of obligated capital
approved by the fiscal intermediaries. However, our impact analysis
of payment changes for capital-related costs is still limited by the
lack of hospital-specific data on several items: 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
[[Page 41632]]
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 fiscal 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 fiscal 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 fiscal intermediary determinations
of projected aggregate obligated capital amounts. We still do not
know, however, 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 final 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 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 are 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 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 final 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 March 1999 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
April 1, 1999 in the provider-specific file. We used these data to
determine the 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 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....................................................... 0.37
1999....................................................... 1.00
2000....................................................... 1.00
------------------------------------------------------------------------
The Medicare case-mix index will decrease by 0.5
percent in FY 1999 and increase by 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 FY
2000 update is 0.3 percent (see section IV of the Addendum to this
final 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:
Capital Transition Payment Methodology for FY 2000
----------------------------------------------------------------------------------------------------------------
Percent of Percent of
Type of hospital Percent of Percent of capital capital
hospitals discharges costs payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital........................................... 66 61 53 59
High Cost Hospital.......................................... 34 39 47 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 Federal
rate, we estimate aggregate Medicare capital payments will increase
by 3.64 percent in FY 2000.
[[Page 41633]]
Table III.--Impact of Final 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...................... 3,203 6,746,008 $518.19 81.46 $59.00 $3.39 $8.65 $589.23 ..........
Fully Prospective................... 2,983 16,158,921 507.63 80.00 64.62 .......... 7.26 579.51 ..........
100% Federal Rate................... 185 517,623 652.10 100.00 .......... .......... 5.01 657.11 ..........
Hold Harmless....................... 35 69,464 456.70 69.51 .......... 329.49 158.88 945.07 ..........
High Cost Hospitals..................... 1,640 4,259,861 649.03 97.08 .......... 27.20 15.52 691.75 ..........
100% Federal Rate................... 1,425 3,846,137 664.09 100.00 .......... .......... 9.25 673.35 ..........
Hold Harmless....................... 215 413,723 508.96 71.69 .......... 280.11 73.75 862.82 ..........
Total Hospitals................. 4,843 11,005,868 568.83 87.69 36.16 12.61 11.31 628.91 ..........
FY 2000 Payments per Discharge:
Low Cost Hospitals...................... 3,203 6,814,738 $573.54 90.68 $29.43 $2.32 $11.72 $617.01 4.71
Fully Prospective................... 2,983 6,221,683 568.06 90.00 32.23 .......... 8.39 608.68 5.03
100% Federal Rate................... 190 542,491 643.37 100.00 .......... .......... 17.97 661.34 0.64
Hold Harmless....................... 30 50,564 499.44 74.17 .......... 312.08 354.68 1,166.20 23.40
High Cost Hospitals..................... 1,640 4,303,107 641.55 97.57 .......... 22.65 25.76 689.96 -0.26
100% Federal Rate................... 1,432 3,901,155 653.77 100.00 .......... .......... 15.41 669.18 -0.62
Hold Harmless....................... 208 401,953 522.90 75.31 .......... 242.47 126.27 891.65 3.34
Total Hospitals................. 4,843 11,117,846 599.86 93.41 18.04 10.19 17.16 645.25 2.60
--------------------------------------------------------------------------------------------------------------------------------------------------------
We project that low capital cost hospitals paid under the fully
prospective payment methodology will experience an average increase
in payments per case of 5.03 percent, and high capital cost
hospitals will experience an average decrease of 0.26 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.
We project that low capital cost hospitals paid under the hold-
harmless payment methodology will experience an average increase in
payments per case of 23.40 percent over FY 1999. Because this group
of hospitals consists of such a small number of hospitals, when
determining the percentage change over FY 2000, a slight change in
the number of hospitals in that group (35 hospitals in FY 1999
compared to 30 hospitals in FY 2000) results in a large percentage
change. That is, the five hospitals that left this group from FY
1999 to FY 2000 were lower cost hospitals, so that there are fewer
hospitals in this group over which to distribute their total capital
payments. As a result, the remaining hospitals in this group are
projected to receive a larger increase in payments over FY 1999.
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 71.69 percent to 75.31
percent. We estimate the percentage of hold-harmless hospitals paid
based on 100 percent of the Federal rate will increase from 86.9
percent to 87.3 percent. We estimate that the few remaining high
cost hold-harmless hospitals (208) will experience an increase in
payments of 3.34 percent from FY 1999 to FY 2000. This estimate
differs from our projection (8.38 percent) in the proposed rule; in
the proposed rule, we estimated a larger increase in exception
payments for these hospitals between FY 1999 and FY 2000 than we are
now projecting in this final rule.
We expect that the average hospital-specific rate payment per
discharge will decrease from $64.62 in FY 1999 to $32.23 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 have made no changes in our exceptions policies for FY 2000.
As a result, the minimum payment levels are--
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 1.80
percent of total capital payments in FY 1999 to 2.66 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.............................. 171 42
High Capital Cost............................. 216 58
-------------------------
Total..................................... 387 100
------------------------------------------------------------------------
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 (Estimated for FY 2000)
----------------------------------------------------------------------------------------------------------------
(2) Hold-harmless
-------------------------- (3)
(1) Total Percentage Percentage Percentage
No. of paid hold- paid fully paid fully
hospitals harmless federal prospective
(A) (B) rate
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals........................................... 4,843 4.9 33.5 61.6
Large urban areas (populations over 1 million).......... 1,546 5.2 41.1 53.6
Other urban areas (populations of 1 million or fewer)... 1,167 6.5 41.0 52.4
Rural areas............................................. 2,130 3.8 23.8 72.4
Urban hospitals......................................... 2,713 5.8 41.1 53.1
[[Page 41634]]
0-99 beds........................................... 670 7.2 33.3 59.6
100-199 beds........................................ 927 7.9 47.6 44.6
200-299 beds........................................ 552 4.7 41.8 53.4
300-499 beds........................................ 422 1.2 39.3 59.5
500 or more beds.................................... 142 3.5 38.0 58.5
Rural hospitals......................................... 2,130 3.8 23.8 72.4
0-49 beds........................................... 1,187 3.1 17.2 79.7
50-99 beds.......................................... 568 5.1 28.7 66.2
100-149 beds........................................ 223 6.3 36.3 57.4
150-199 beds........................................ 87 0.0 32.2 67.8
200 or more beds.................................... 65 1.5 47.7 50.8
By Region:
Urban by Region......................................... 2,713 5.8 41.1 53.1
New England......................................... 148 1.4 27.7 70.9
Middle Atlantic..................................... 415 4.1 34.9 61.0
South Atlantic...................................... 402 5.7 52.5 41.8
East North Central.................................. 463 5.4 31.5 63.1
East South Central.................................. 158 9.5 48.1 42.4
West North Central.................................. 181 4.4 39.2 56.4
West South Central.................................. 332 11.7 58.1 30.1
Mountain............................................ 124 2.4 53.2 44.4
Pacific............................................. 443 5.2 34.8 60.0
Puerto Rico......................................... 47 4.3 25.5 70.2
Rural by Region......................................... 2,130 3.8 23.8 72.4
New England......................................... 52 1.9 23.1 75.0
Middle Atlantic..................................... 77 6.5 19.5 74.0
South Atlantic...................................... 279 1.4 34.4 64.2
East North Central.................................. 282 2.1 20.2 77.7
East South Central.................................. 267 3.0 32.6 64.4
West North Central.................................. 491 3.3 16.3 80.4
West South Central.................................. 338 5.0 26.6 68.3
Mountain............................................ 200 8.0 17.5 74.5
Pacific............................................. 139 5.8 24.5 69.8
Large urban areas (populations over 1 million).......... 1,624 5.0 41.1 53.8
Other urban areas (populations of 1 million or fewer)... 1,165 6.5 40.6 52.9
Rural areas............................................. 2,054 3.9 23.4 72.7
Teaching Status:
Non-teaching........................................ 3,731 5.1 32.9 61.9
Fewer than 100 Residents................................ 870 4.7 36.2 59.1
100 or more Residents................................... 242 2.5 32.2 65.3
Disproportionate share hospitals (DSH):
Non-DSH................................................. 2,997 4.9 29.3 65.8
Urban DSH:
100 or more beds.................................... 1,383 5.0 44.1 50.9
Less than 100 beds.................................. 87 8.0 23.0 69.0
Rural DSH:
Sole Community (SCH/EACH)............................... 158 5.1 22.8 72.2
Referral Center (RRC/EACH).............................. 60 3.3 48.3 48.3
Other Rural:
100 or more beds.................................... 49 4.1 40.8 55.1
Less than 100 beds.................................. 109 2.8 25.7 71.6
Urban teaching and DSH:
Both teaching and DSH................................... 715 3.8 36.9 59.3
Teaching and no DSH..................................... 331 5.7 32.3 61.9
No teaching and DSH..................................... 755 6.5 48.5 45.0
No teaching and no DSH.................................. 988 6.4 40.9 52.7
Rural Hospital Types:
Non special status hospitals............................ 842 1.9 24.3 73.8
RRC/EACH................................................ 154 1.9 42.2 55.8
SCH/EACH................................................ 647 7.6 21.0 71.4
Medicare-dependent hospitals (MDH)...................... 354 1.7 16.9 81.4
SCH, RRC and EACH....................................... 57 10.5 26.3 63.2
Type of Ownership:
Voluntary............................................... 2,821 4.5 32.9 62.6
Proprietary............................................. 732 8.5 57.8 33.7
[[Page 41635]]
Government.............................................. 1,257 3.7 21.0 75.3
Medicare Utilization as a Percent of Inpatient Days:
0-25.................................................... 375 5.3 28.5 66.1
25-50................................................... 1,770 5.2 35.9 58.9
50-65................................................... 1,885 4.8 32.6 62.6
Over 65................................................. 779 4.4 33.0 62.6
----------------------------------------------------------------------------------------------------------------
As we explain in Appendix B of this final rule, we were not able
to determine a hospital-specific rate for 79 of the 4,922 hospitals
in our database. Consequently, the payment methodology distribution
is based on 4,843 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 33.5 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 ``Capital Transition Payment Methodology for FY 2000,''
shown previously in section VII.B.2 of this impact analysis, 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 (72.4 percent and 75.3 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 33.7
percent of proprietary hospitals are being paid under the fully
prospective methodology. This is a reflection of their higher than
average capital costs per case. (We found, at the time of the August
30, 1991 final rule (56 FR 43430), that 62.7 percent of proprietary
hospitals had a capital cost per case above the national average
cost per case.)
D. Cross-Sectional Analysis of Changes in Aggregate Payments
We used our FY 2000 actuarial model to estimate the potential
impact of our changes for FY 2000 on total capital payments per
case, using a universe of 4,843 hospitals. The individual hospital
payment parameters are taken from the best available data,
including: the April 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 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 0.28
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 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 2.6 percent in FY 2000, despite
the effect of the 0.9 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 (2.5 percent and 3.2 percent,
respectively). This is due to the differing impact on urban
hospitals relative to rural hospitals (-1.1 percent and 0.2 percent,
respectively) from Federal rate changes alone. Urban hospitals will
gain approximately the same as rural hospitals (3.6 percent and 3.0
percent, respectively) 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 0.4 percent decrease (West South
Central urban region) to a high of 5.2 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 (3.7 percent,
a 4.2 percent increase from the effects of all other changes and a
0.5 percent decrease due to Federal rate changes). Payments to
voluntary hospitals will increase 2.7 percent (a 3.6 percent
increase from the effects of all other changes and a 0.9 percent
decrease due to Federal rate changes), and payments to proprietary
hospitals will increase 0.7 percent (a 2.2 percent increase from the
effects of all other changes and a 1.5 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 FYs 1999
through 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.
[[Page 41636]]
Hospitals reclassified for FY 2000 as a whole are projected to
experience a 3.7 percent increase in payments (a 3.5 percent
increase attributable to the effects of all other changes and a 0.2
percent increase attributable to Federal rate changes). Payments to
nonreclassified hospitals will increase less (2.5 percent) than
reclassified hospitals (3.7 percent) overall. While payments to
reclassified hospitals will increase (0.2 percent) from the Federal
rate changes, payments to nonreclassified hospitals will decrease by
1.1 percent from the Federal rate changes. However, they will both
gain about the same from the effects of all other changes (3.5
percent compared to 3.6 percent).
Table V.--Comparison of Total Payments Per Case
[FY 1999 Payments Compared to FY 2000 Payments]
----------------------------------------------------------------------------------------------------------------
Portion
Number of Average FY Average FY attributable
hospitals 1999 Pay- 2000 Pay- All changes to federal
ments/case ments/case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................. 4,843 629 645 2.6 -0.9
Large urban areas (populations over 1 1,546 729 745 2.2 -1.1
million).................................
Other urban areas (populations of 1 1,167 616 634 3.0 -1.0
million or fewer)........................
Rural areas............................... 2,130 418 432 3.2 0.2
Urban hospitals........................... 2,713 681 698 2.5 -1.1
0-99 beds............................. 670 499 506 1.4 -1.0
100-199 beds.......................... 927 597 613 2.8 -1.0
200-299 beds.......................... 552 649 663 2.2 -1.0
300-499 beds.......................... 422 701 723 3.1 -1.0
500 or more beds...................... 142 899 917 2.0 -1.4
Rural hospitals........................... 2,130 418 432 3.2 0.2
0-49 beds............................. 1,187 343 358 4.6 0.6
50-99 beds............................ 568 391 409 4.5 0.3
100-149 beds.......................... 223 436 448 2.8 0.3
150-199 beds.......................... 87 451 464 2.9 0.0
200 or more beds...................... 65 535 539 0.8 -0.4
By Region:
Urban by Region........................... 2,713 681 698 2.5 -1.1
New England........................... 148 691 721 4.3 -0.2
Middle Atlantic....................... 415 752 766 1.8 -1.3
South Atlantic........................ 402 665 690 3.8 -0.9
East North Central.................... 463 638 659 3.3 -0.5
East South Central.................... 158 629 643 2.2 -1.1
West North Central.................... 181 669 691 3.4 -1.2
West South Central.................... 332 669 672 0.4 -2.0
Mountain.............................. 124 648 660 1.8 -0.8
Pacific............................... 443 755 768 1.7 -1.4
Puerto Rico........................... 47 293 296 1.0 -1.6
Rural by Region........................... 2,130 418 432 3.2 0.2
New England........................... 52 499 516 3.5 0.0
Middle Atlantic....................... 77 441 455 3.1 -0.2
South Atlantic........................ 279 435 445 2.5 -0.1
East North Central.................... 282 427 438 2.6 0.2
East South Central.................... 267 385 398 3.5 0.6
West North Central.................... 491 405 427 5.2 0.8
West South Central.................... 338 375 385 2.5 -0.1
Mountain.............................. 200 439 454 3.4 0.4
Pacific............................... 139 495 513 3.6 -0.8
By Payment Classification:
All hospitals............................. 4,843 629 645 2.6 -0.9
Large urban areas (populations over 1 1,624 722 738 2.2 -1.1
million).................................
Other urban areas (populations of 1 1,165 614 633 3.0 -1.0
million or fewer)........................
Rural areas............................... 2,054 415 429 3.3 0.2
Teaching Status:..........................
Non-teaching.......................... 3,731 524 538 2.7 -0.7
Fewer than 100 Residents.......... 870 661 676 2.3 -1.1
100 or more Residents............. 242 951 978 2.8 -1.1
Urban DSH:
100 or more beds.................. 1,383 721 739 2.5 -1.1
Less than 100 beds................ 87 503 503 0.1 -0.4
Rural DSH:
Sole Community (SCH/EACH)......... 158 371 385 3.7 0.8
Referral Center (RRC/EACH)........ 60 474 484 2.1 0.0
Other Rural:
100 or more beds.................. 49 378 386 2.1 0.2
Less than 100 beds................ 109 327 342 4.8 1.2
Urban teaching and DSH:
Both teaching and DSH................. 715 794 813 2.4 -1.2
Teaching and no DSH................... 331 680 699 2.8 -1.1
No teaching and DSH................... 755 596 613 2.8 -1.0
[[Page 41637]]
No teaching and no DSH................ 988 564 577 2.2 -1.0
Rural Hospital Types:
Non special status hospitals.......... 842 369 382 3.5 0.4
RRC/EACH.............................. 154 484 496 2.5 -0.3
SCH/EACH.............................. 647 410 427 4.0 0.3
Medicare-dependent hospitals (MDH).... 354 344 360 4.6 0.4
SCH, RRC and EACH..................... 57 489 502 2.6 0.5
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY99
and FY00:
Reclassified During Both FY99 and 370 546 563 3.0 -0.7
FY00.............................
Reclassified During FY00 Only..... 127 528 563 6.7 3.6
Reclassified During FY99 Only..... 146 518 508 -2.0 -4.3
FY00 Reclassifications:
All Reclassified Hospitals........ 498 543 563 3.7 0.2
All Nonreclassified Hospitals..... 4,319 640 656 2.5 -1.1
All Urban Reclassified Hospitals.. 83 715 745 4.1 -0.7
Urban Nonreclassified Hospitals... 2,604 680 697 2.4 -1.1
All Reclassified Rural Hospitals.. 415 479 496 3.5 0.6
Rural Nonreclassified Hospitals... 1,715 377 388 3.0 -0.3
Other Reclassified Hospitals (Section 26 456 470 3.0 1.8
1886(D)(8)(B)).......................
Type of Ownership:
Voluntary............................. 2,821 643 661 2.7 -0.9
Proprietary........................... 732 625 630 0.7 -1.5
Government............................ 1,257 552 572 3.7 -0.5
Medicare Utilization as a Percent of
Inpatient Days:
0-25.................................. 375 762 781 2.4 -1.5
25-50................................. 1,770 724 740 2.2 -1.1
50-65................................. 1,885 567 585 3.1 -0.8
----------------------------------------------------------------------------------------------------------------
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 final rule: the March 31, 1999 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 April 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 excluded from 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
------------------------------------------------------------------------
Provider-Specific File Only................................ 145
Provider-Specific and Audit File........................... 4,777
------------
Total.................................................... 4,922
------------------------------------------------------------------------
Of the 4,922 hospitals, 105 had unusable or missing data or had
no cost reports available. For 23 of the 105 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
two hospitals and from the PPS-X cost report data for one more
hospital. Hence, we were able to use 26 of the 105 hospitals. We
used 4,843 hospitals for the analysis. Seventy-nine hospitals could
not be used in the analysis because of insufficient information.
These hospitals account for less than 0.3 percent of admissions.
Therefore, any effects from the elimination of their cost report
data should be minimal.
We analyzed changes in capital-related costs (depreciation,
interest, rent, leases, insurance, and taxes) reported in the cost
reports. We found a wide variance among
[[Page 41638]]
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 cost 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 had 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 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 FY 2000 DRG relative weights
included in section VI. of the Addendum to this final 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 decrease 0.5 percent in FY 1999. We project that case-mix will
increase 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
and earlier 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,
[[Page 41639]]
an incremental budget neutrality adjustment of 0.99857 for FY 2000
should be applied to the previous cumulative FY 1999 adjustment of
1.00294, yielding a cumulative adjustment of 1.00151 through FY
2000. For the Puerto Rico geographic adjustment factor, an
incremental budget neutrality adjustment of 0.99910 for FY 2000
should be applied to the previous cumulative FY 1999 adjustment of
1.00233, yielding a cumulative adjustment of 1.00143 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 0.99991 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 1.00142 nationally, and 1.00134 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..................................... 0.99857 0.99991 0.99848 1.00142 0.99910 0.99991 0.99901 1.00134
--------------------------------------------------------------------------------------------------------------------------------------------------------
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 addon 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 final factors for FY 2000, and the estimated factors that
would be applicable through FY 2004. We caution that these are
estimates for FYs 2001 and later, and are subject to revisions
resulting from continued methodological refinements, receipt of
additional data, and changes in payment policy. We note that in
making these projections, we have assumed that the cumulative
national DRG/GAF budget neutrality adjustment factor will remain at
1.00142 (1.00134 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......................................................... 0.30 .9730 N/A .9985 .9402 ........... 377.03
2001......................................................... 0.50 .9636 N/A 5 1.0000 5 .9402 ........... 375.26
2002......................................................... 0.50 6 1.0000 N/A 1.0000 .9402 ........... 391.38
2003......................................................... 0.50 6 1.0000 N/A 1.0000 .9402 4 1.0255 403.38
[[Page 41640]]
2004......................................................... 0.50 6 1.0000 N/A 1.0000 .9402 ........... 405.40
--------------------------------------------------------------------------------------------------------------------------------------------------------
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: 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
updating 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 second quarter 1999 forecast of the FY 2000
market basket increase of 2.9 percent for hospitals subject to the
prospective payment system, the updates in the standardized amounts
are 1.1 percent for hospitals in both large urban and other areas.
The update in the hospital-specific rate applicable to sole
community and Medicare-dependent, small rural hospitals is also 1.1
percent. The update for hospitals excluded from the prospective
payment system can be as high as the percentage increase in the
excluded hospital market basket (currently estimated at 2.9 percent)
or as low as zero, depending on the hospital's costs in relation to
its rate-of-increase limit. (See Section V of the Addendum to this
final rule.)
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. 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.
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, we published the FY 2000 update factors recommended by
the Secretary as Appendix D of the May 7, 1999 proposed rule (64 FR
24852).
Under section 1886(e)(4) of the Act, we recommended that an
appropriate update factor for the standardized amounts was 0.0
percentage points for hospitals located in large urban and other
areas. We also recommended 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 stated that we
believe our 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.
In the proposed rule, we recommended that hospitals excluded
from the prospective payment system receive an update of between 0
and 2.6 percentage points. The recommended update for excluded
hospitals and units was 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. For the proposed rule, the market basket rate of increase was
forecast at 2.6 percent. This recommendation was consistent with the
President's FY 2000 budget, although we noted that the market basket
rate of increase was forecast at 2.7 percent when the budget was
submitted.
II. Secretary's Final Recommendations for Updating the Prospective
Payment System Standardized Amounts
We received seven comments concerning our proposed
recommendations, two of which commented directly on the update
recommendation. Our final recommendations for the operating update
for both prospective and excluded hospitals do not differ from the
proposed. However, the second quarter forecast of the market basket
percentage increase is 2.9 for prospective payment hospitals (up
from 2.7 estimated in the proposed rule) and 2.9 for excluded
hospitals and units (up from 2.6 estimated in the proposed rule).
Comment: Several commenters expressed support for our proposal
to update hospital payment rates on October 1, 1999, rather than
delaying the update because of concerns about ``Year 2000'' (Y2K)
systems issues. One commenter, while acknowledging that we are
required to use the factors set in current law to update payment
rates, expressed concern that an update to the rates less than the
full market basket rate of increase is inadequate, forcing hospitals
to forego technological advances that may improve quality and
patient outcomes. Another commenter believes that the proposed
updates would place more financial hardship on hospitals, in
particular teaching hospitals, by freezing or reducing payment
rates.
Response: We appreciate the support from commenters. As the one
commenter noted, we are required by section 1886(b)(3) of the Act,
as amended by the Balanced Budget Act of 1997 (BBA), to update rates
for FY 2000 by the estimated increase in the hospital market basket
minus 1.8 percentage points. Our latest available data show that
hospital costs per case are continuing to decline while payments per
case are increasing, resulting in high average Medicare profit
margins across all hospitals. Therefore, we believe that the update
to payment rates specified by law for FY 2000 is sufficient to allow
hospitals to continue providing Medicare beneficiaries with
efficient care of high quality. We will continue to monitor the
financial performance of hospitals as newer data become available
and will adjust our future update recommendations to Congress as
appropriate.
Comment: MedPAC stated that while HCFA's proposed update
recommendation of zero percentage points is within the range that
MedPAC adopted in its own recommendation, the Commission believes
[[Page 41641]]
that the update specified in law is appropriate because the effects
of the BBA are not yet fully evident. Reducing payments below the
level prescribed by law would not be prudent, at least for FY 2000.
MedPAC further stated that it will monitor the financial performance
of hospitals under BBA during the coming year.
Response: As we stated in the proposed rule, we believe that our
recommendation (an update of zero percentage points) is an
appropriate response to 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. Furthermore, as a prudent
purchaser of health care for Medicare beneficiaries, we believe it
is important that we maintain incentives to hospitals to provide
high quality care efficiently. Like MedPAC, we, too, will continue
to monitor the financial performance of hospitals and adjust future
update recommendations as appropriate.
III. Secretary's Final Recommendation for Updating the Rate-of-Increase
Limits for Excluded Hospitals
We received one comment concerning our proposed recommendation
for updating the rate-of-increase limits for excluded hospitals.
Comment: MedPAC recommended adding 0.4 percentage points to the
market basket forecast before applying the update formula to account
for technical improvements that hospitals must make related to Y2K-
related computer problems. MedPAC believes Y2K-related computer
malfunctions could potentially compromise patient care by
interrupting service continuity, thereby creating substantial
liability exposure for hospitals. Therefore, HCFA should increase
the market basket forecast to account for the additional costs
hospitals will incur in making computer system improvements to avoid
Y2K problems.
Response: Our final recommendation is that hospitals and
hospital units excluded from the prospective payment system receive
an update using a market basket increase estimate of 2.9 percentage
points. This update is consistent with the updates provided to the
prospective payment hospitals. We note that under our update
framework for excluded hospitals and units, the analysis indicates
identical findings to those for prospective payment system hospitals
regarding changes in productivity, scientific and technological
advances, practice patterns, and case-mix for FY 2000. We believe
these updates will ensure that Medicare acts as a prudent purchaser
and will provide incentives to hospitals for increased efficiency.
Thus, using the statutory target amount update formula, the update
factor for an excluded hospital or unit will be between 0.4 percent
and 2.9 percent, or 0.
[FR Doc. 99-19334 Filed 7-29-99; 8:45 am]
BILLING CODE 4120-03-P