[Federal Register Volume 66, Number 148 (Wednesday, August 1, 2001)]
[Rules and Regulations]
[Pages 39828-40102]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-18868]
[[Page 39827]]
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Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 405, 410, 412, et al.
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Rates and Costs of Graduate Medical Education; Fiscal Year
2002 Rates, Etc.; Final Rules
Federal Register / Vol. 66, No. 148 / Wednesday, August 1, 2001 /
Rules and Regulations
[[Page 39828]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 410, 412, 413, 482, 485, and 486
[CMS 1131-F, CMS 1158-F, and CMS 1178-F]
RINs 0938-AK20; 0938-AK73; and 0938-AK74
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Rates and Costs of Graduate Medical Education:
Fiscal Year 2002 Rates; Provisions of the Balanced Budget Refinement
Act of 1999; and Provisions of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rules.
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SUMMARY: We are revising the Medicare hospital inpatient prospective
payment systems for operating and capital costs to: implement
applicable statutory requirements, including a number of provisions of
the Medicare, Medicaid, and SCHIP [State Children's Health Insurance
Program] Benefits Improvement and Protection Act of 2000 (Public Law
106-554); and implement changes arising from our continuing experience
with these systems. In addition, in the Addendum to this final rule, we
describe changes to the amounts and factors used to determine the rates
for Medicare hospital inpatient services for operating costs and
capital-related costs. These changes apply to discharges occurring on
or after October 1, 2001. We also set forth the rate-of-increase limits
as well as policy changes for hospitals and hospital units excluded
from the prospective payment systems.
We are making changes to the policies governing payments to
hospitals for the direct costs of graduate medical education and
critical access hospitals.
Lastly, we are responding to public comments received on the
following two related interim final rules that we published in the
Federal Register and finalizing those interim rules:
An August 1, 2000 interim final rule with comment period
(65 FR 47026, HCFA-1131-IFC) that implemented, or conformed the
regulations to, certain statutory provisions relating to Medicare
payments to hospitals for inpatient services that were contained in the
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
(Public Law 106-113), and that were effective during FY 2000. These
provisions related to reclassification of hospitals from urban to rural
status, reclassification of certain hospitals for purposes of payment
during fiscal year 2000, critical access hospitals, payments to
hospitals excluded from the prospective payment system, and payments
for indirect and direct graduate medical education costs.
A June 13, 2001 interim final rule with comment period (66
FR 32172, HCFA-1178-IFC) that implemented, or conformed the regulations
to, certain statutory provisions relating to Medicare payments to
hospitals for inpatient services that were contained in Public Law 106-
554, and that were effective prior to passage of Public Law 106-554 on
December 21, 2000; on April 1, 2001; or on July 1, 2001. Many of the
provisions of Public Law 106-554 modified changes to the Social
Security Act made by Public Law 106-113 or the Balanced Budget Act of
1997 (Public Law 105-33), or both.
EFFECTIVE DATE: The provisions of this final rule are effective October
1, 2001. This rule is a major rule as defined in 5 U.S.C. 804(2).
Pursuant to 5 U.S.C. 801(a)(1)(A), we are submitting a report to
Congress on this rule on August 1, 2001.
FOR FURTHER INFORMATION CONTACT: Stephen Phillips, (410) 786-4548,
Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage
Index, Hospital Geographic Reclassifications, Sole Community Hospitals,
Disproportionate Share Hospitals, and Medicare-Dependent, Small Rural
Hospitals Issues; Tzvi Hefter, (410) 786-4487, Capital Prospective
Payment, Excluded Hospitals, Graduate Medical Education and Critical
Access Hospitals 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). Each DRG has a payment weight assigned
to it, based on the average resources used to treat Medicare patients
in that DRG.
Under section 1886(d)(1)(B) of the Act in effect without
consideration of the amendments made by Public Law 105-33, Public Law
106-113, and Public Law 106-554, certain specialty hospitals are
excluded from the hospital inpatient prospective payment system:
psychiatric hospitals and units, rehabilitation hospitals and 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,
until the payment provisions of Public Laws 105-33, 106-113, and 106-
554 that are applicable to three classes of these hospitals are
implemented, as discussed below.
[[Page 39829]]
Various sections of Public Laws 105-33, 106-113, and 106-554
provide for the transition of rehabilitation hospitals and units,
psychiatric hospitals and units, and long-term care hospitals from
being paid on an excluded hospital basis to being paid on an individual
prospective payment system basis. These provisions are as follows:
Rehabilitation Hospitals and Units. Section 1886(j) of the
Act, as added by section 4421 of Public Law 105-33 and amended by
section 125 of Public Law 106-113 and section 305 of Public Law 106-
554, authorizes the implementation of a prospective payment system for
inpatient hospital services furnished by rehabilitation hospitals and
units. Section 4421 of Public Law 105-33 amended the Act by adding
section 1886(j). Section 1886(j) of the Act provides for a fully
implemented prospective payment system for inpatient rehabilitation
hospitals and rehabilitation units, effective for cost reporting
periods beginning during or after October 2002, with payment provisions
during a transitional period based on target amounts specified in
section 1886(b) of the Act. Section 125 of Public Law 106-113 amended
section 1886(j) of the Act to require the Secretary to use a discharge
as the payment unit for inpatient rehabilitation services under the
prospective payment system and to establish classes of patient
discharges by functional-related groups. Section 305 of Public Law 106-
554 further amended section 1886(j) of the Act to allow hospitals to
elect to be paid the full Federal prospective payment rather than the
transitional period payments specified in the Act. A final rule
implementing the prospective payment system for inpatient
rehabilitation hospitals will be published in the Federal Register
shortly.
Psychiatric Hospitals and Units. Sections 124(a) and (c)
of Public Law 106-113 provide for the development of a per diem
prospective payment system for payment for inpatient hospital services
of psychiatric hospitals and units under the Medicare program,
effective for cost reporting periods beginning on or after October 1,
2002. This system must include an adequate patient classification
system that reflects the differences in patient resource use and costs
among these hospitals and must maintain budget neutrality. We are in
the process of developing a proposed rule, to be followed by a final
rule, to implement the prospective payment system for psychiatric
hospitals and units, effective for October 1, 2002.
Long-Term Care Hospitals. Sections 123(a) and (c) of
Public Law 106-113 provide for the development of a per discharge
prospective payment system for payment for inpatient hospital services
furnished by long-term care hospitals under the Medicare program,
effective for cost reporting periods beginning on or after October 1,
2002. Section 307(b)(1) of Public Law 106-554 provides that payments
under the long-term care prospective payment system will be made on a
prospective payment basis rather than a cost basis. The long-term care
hospital prospective payment system must include a patient
classification system that reflects the differences in patient resource
use and costs, and must maintain budget neutrality. We are planning to
develop a proposed rule, to be followed by a final rule, to implement
the prospective payment system for long-term care hospitals, effective
for October 1, 2002. Section 307 of Public Law 106-554 provides that if
the Secretary is unable to develop a prospective payment system for
long-term care hospitals that can be implemented by October 1, 2002,
the Secretary must implement a prospective payment system that bases
payment under the system using the existing acute hospital DRGs,
modified where feasible to account for resource use of long-term care
hospital patients using the most recently available hospital discharge
data for long-term care services.
Under sections 1820 and 1834(g) of the Act, payments are made to
critical access hospitals (CAHs) (that is, rural hospitals or
facilities that meet certain statutory requirements) for inpatient and
outpatient services on a reasonable cost basis. Reasonable cost is
determined under the provisions of section 1861(v)(1)(A) of the Act and
existing regulations under Parts 413 and 415.
Under section 1886(a)(4) of the Act, costs of approved educational
activities are excluded from the operating costs of inpatient hospital
services. Hospitals with approved graduate medical education (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 acute care hospital inpatient
prospective payment system are located in 42 CFR part 412. The
regulations governing excluded hospitals and hospital units are located
in Parts 412 and 413. The regulations governing GME payments are
located in Part 413. The regulations governing CAHs are located in
Parts 413 and 485.
This final rule implements amendments enacted by Public Law 106-554
relating to updates to FY 2002 payments for hospital inpatient
services, hospitals' geographic reclassifications and wage indexes, GME
costs, the payment adjustment for disproportionate share hospitals
(DSHs), the indirect medical education (IME) adjustment for teaching
hospitals, and CAHs. It also implements other changes affecting DRG
classifications and relative weights, annual updates to the data used
to calculate the wage index, sole community hospitals (SCHs), payments
under the inpatient capital prospective payment system, and policies
related to hospitals and units excluded from the prospective payment
system. These changes are addressed in sections II., III., IV., and VI.
of this preamble.
Section 533 of Public Law 106-554 requires the Secretary to
establish a mechanism to recognize the costs of new medical services
and technologies by October 1, 2001. We proposed a mechanism in the May
4, 2001 proposed rule. We received 61 comments on our proposed criteria
to qualify for this special payment and on the proposed mechanism to
pay for qualifying new technologies. Due to this large number of
comments, we will publish a separate final rule to respond to comments
received on our proposal, and to establish a mechanism, by October 1,
2001.
Although we intend to establish the mechanism by October 1, 2001,
we will not make additional payments under the mechanism for cases
involving new technology during FY 2002 because it is not feasible.
This is due to the timing of the enactment of Public Law 106-554 on
December 21, 2000, the requirement that we establish the mechanism
through notice and an opportunity for public comment, and the
requirement that the payments be implemented in a budget neutral
manner. That is, it was not feasible to establish the criteria by which
new technologies would qualify through a proposed rule with opportunity
for public comment as part of the May 4, 2001 proposed rule, finalize
those criteria in response to public comments, allow technologies to
qualify under those criteria, and implement payments for any qualified
technologies in a budget neutral manner. This is because making the
special payments in a budget neutral manner requires an adjustment to
the standardized amounts (which must be published in final by August 1
each year).
[[Page 39830]]
Representatives of new technologies seeking to qualify for special
payments under this provision for FY 2003 should proceed with their
application by contacting us at the telephone numbers listed in the
``For Further Information Contact'' section of this preamble. As
indicated previously, a final rule containing the specific qualifying
criteria and payment mechanism will be published shortly.
This final rule also responds to public comments on, and finalizes
implementation of, provisions of Public Law 106-113 that relate to
Medicare payments to hospitals for FY 2001 that were addressed in a
separate interim final rule with comment period (HCFA-1131-IFC),
published in the Federal Register on August 1, 2000 (65 FR 47026).
Lastly, this final rule responds to public comments on, and
finalizes implementation of, other provisions of Public Law 106-554
that relate to Medicare payments to hospitals effective prior to
October 1, 2001 (that is, for FY 2001 or for the period between April
l, 2001 and September 30, 2001) that were addressed in a separate
interim final rule with comment period (HCFA-1178-IFC), published in
the Federal Register on June 13, 2001 (66 FR 32172).
In summary, this final rule responds to public comments on, and
finalizes, three documents published in the Federal Register: The
August 1, 2000 interim final rule with comment period, the May 4, 2001
proposed rule (HCFA-1158-P), and the June 13, 2001 interim final rule
with comment period, as discussed below.
The charts below specify the effective dates of the various
provisions of Public Law 106-113 and Public Law 106-554.
Effective Dates of the Provisions of Public Law 106-113 Included in This
Final Rule
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Section No. Title Effective date
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111......................... Indirect Medical 10/01/1999.
Education
Adjustment Formula.
121......................... Wage Adjustment to 10/01/1999.
Caps on Target
Amounts for
Excluded Hospitals
and Units.
152(a)...................... Reclassified 10/01/1999.
Hospitals in
Certain Designated
Counties.
153......................... Calculation of Wage 10/01/1999.
Index for
Hattiesburg,
Mississippi.
154......................... Calculation of Wage 10/01/1999.
Index for Allentown-
Bethlehem-Easton,
Pennsylvania MSA.
312......................... Initial Residency 7/01/2000, for
Period for Child residency programs
Neurology Residency that began before,
Programs. on, or after 11/29/
1999.
401(a)...................... Reclassification of 01/01/2000.
Certain Urban
Hospitals to Rural.
401(b)(2)................... Application of 01/01/2000.
Reclassifications
under Section
401(a) to Critical
Access Hospitals.
403(a)...................... Length of Stay 11/29/1999.
Restrictions on
Inpatient Stays in
Critical Access
Hospitals.
403(b)...................... Qualifications of 11/29/1999.
For-Profit
Hospitals for
Critical Access
Hospital Status.
403(c)...................... Qualification of 11/29/1999 for
Closed Hospitals or hospitals that
Hospitals Downsized closed after 11/29/
to Health Clinics 1989; 11/29/1999
for Critical Access for hospitals that
Hospital downsized to health
Designation. clinics.
403(e)...................... Elimination of 11/29/1999.
Medicare Part B
Deductible and
Coinsurance for
Clinical Diagnostic
Laboratory Tests
Furnished in
Critical Access
Hospitals.
403(f)...................... Provisions on Swing- 11/29/1999.
Beds in Critical
Access Hospitals.
404......................... Extension of 10/01/2002 through 9/
Medicare-Dependent, 30/2006.
Small Rural
Hospital Program.
407(a)...................... Residents on 11/29/1999.
Approved Leaves of
Absence--GME and
IME.
407(b)...................... Expansion of Number 04/01/2000.
of Unweighted
Residents in Rural
Hospitals--GME and
IME.
407(c)...................... Urban Hospitals with 04/01/2000.
Rural Training
Tracks or
Integrated Rural
Tracks--GME and IME.
407(d)...................... Residents Training 10/01/1997
at Certain Veterans
Hospitals--GME and
IME.
408(a)...................... Swing Beds for 07/01/1998 through
Skilled Nursing the end of the
Facility Level of facility's third
Care Patients. cost reporting
period after this
date.
408(b)...................... Elimination of 07/01/1998 through
Constraints on the end of the
Length of Stay in facility's third
Swing Beds in Rural cost reporting
Hospitals. period after this
date.
541......................... Additional Payments 01/01/2000.
to Hospitals for
Approved Nursing
and Allied Health
Education to
Reflect Utilization
of Medicare+Choice
Enrollees.
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Effective Dates of the Provisions of Public Law 106-113 Included in This Final Rule
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Section No. Title Effective date
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201............................. Clarification of No 11/29/1999.
Beneficiary Cost-
Sharing for Clinical
Diagnostic Laboratory
Tests Furnished by
Critical Access
Hospitals.
202............................. Assistance with Fee 07/01/2001.
Schedule Payment for
Professional Services
under All-Inclusive
Rate.
211............................. Threshold for 04/01/2001.
Disproportionate Share
Hospitals.
[[Page 39831]]
212............................. Option to Base 04/01/2001.
Eligibility for
Medicare-Dependent,
Small Rural Hospital
Program on Discharges
during Two of the
Three Most Recently
Audited Cost Reporting
Periods.
213............................. Extension of Option to 10/01/2000.
use Rebased Target
Amounts to All Sole
Community Hospitals.
301............................. Revision of Acute Care 04/01/2001.
Hospital Payment
Update for 2001.
302............................. Additional Modification 04/01/2001.
in Transition for
Indirect Medical
Education Adjustment.
303............................. Decrease in Reductions 04/01/2001.
for Disproportionate
Share Hospitals.
304(a).......................... Three-Year Wage Index 10/01/2001.
Reclassifications; Use
of 3 Years of Wage
Data for Evaluating
Reclassifications.
304(b).......................... Statewide Wage Index 10/01/2001 for reclassification beginning 10/01/2002.
for Reclassifications.
304(c).......................... Collection of 09/30/2003 for application 10/1/2004.
Occupational Case Mix
Data.
306............................. Payment for Inpatient 10/01/2000.
Services of
Psychiatric Hospitals.
307............................. Payment for Inpatient 10/01/2000.
Services of Long-Term
Care Hospitals.
511............................. Increase in Floor for 10/01/2001.
Payments for Direct
Costs of Graduate
Medical Education.
512............................. Change in Distribution 01/01/2001.
Formula for
Medicare+Choice-
Related Nursing and
Allied Health
Education Costs.
541............................. Increase in 10/01/2000.
Reimbursement for Bad
Debt.
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B. Summary of the Provisions of the May 4, 2001 Proposed Rule
On May 4, 2001, we published a proposed rule in the Federal
Register (66 FR 22646) that set forth proposed changes to the Medicare
hospital inpatient prospective payment system for operating and
capital-related costs for FY 2002. We set forth proposed changes to the
amounts and factors used in determining the rates for these costs. In
addition, we proposed changes relating to payments for GME costs and
payments to excluded hospitals and units, SCHs, and CAHs.
The following is a summary of the major changes that we proposed
and the issues we addressed in the May 4, 2001 proposed rule:
1. Changes to the DRG Reclassifications and Recalibrations of Relative
Weights
As required by section 1886(d)(4)(C) of the Act, we proposed annual
adjustments to the DRG classifications and relative weights. Based on
analyses of Medicare claims data, we proposed to establish a number of
new DRGs and make changes to the designation of diagnosis and procedure
codes under other existing DRGs for FY 2002.
We also addressed the provisions of section 533 of Public Law 106-
544 regarding development of a mechanism for increased payment for new
medical services and technologies and the required report to Congress
on expeditiously introducing new medical services and technology into
the DRGs.
2. Changes to the Hospital Wage Index
We proposed to use wage data taken from hospitals' FY 1998 cost
reports in the calculation of the FY 2002 wage index. We also proposed
to implement the third year of the phaseout of wage costs related to
GME or Part A certified registered nurse anesthetists (CRNA) from the
FY 2002 wage index calculation.
We proposed several changes to the wage index methodology that
would apply in calculating the FY 2003 wage index, and addressed new
procedures for requesting wage data corrections and a modification of
the process and timetable for updating the wage index.
We also discussed the collection of hospital occupational
mix data as required by section 304(c) of Public Law 106-554.
In addition, we discussed revisions to the wage index
based on hospital redesignations and reclassifications for purposes of
the wage index, including changes to reflect the provisions of sections
304(a) and (b) of Public Law 106-554 relating to 3-year wage index
reclassifications by the MGCRB, the use of 3 years of wage data for
evaluating reclassification requests for FYs 2003 and later, and the
application of a statewide wage index for reclassifications beginning
in FY 2003.
3. Other Decisions and Changes to the Prospective Payment System for
Inpatient Operating and Graduate Medical Education Costs
We discussed several provisions of the regulations in 42 CFR parts
412 and 413 and set forth certain proposed changes concerning SCHs;
rural referral centers; changes relating to the IME adjustment as a
result of section 302 of Public Law 106-554; changes relating to the
DSH adjustment as a result of section 303 of Public Law 106-554; the
establishment of policies relating to the 3-year application of wage
index reclassifications by the MGCRB, the use of 3 years of wage data
in evaluating reclassification requests to the MGCRB for FYs 2003 and
later, and the use of a statewide wage index for reclassifications
beginning in FY 2003, as required by sections 304(a) and (b) of Public
Law 106-554.
We discussed proposed requirements for qualifying for additional
payments for new medical services and technology, as required by
section 533(b) of Public Law 106-554.
Lastly, we proposed changes relating to payment for the direct
costs of GME, including changes as a result of section 511 of Public
Law 106-554.
4. Prospective Payment System for Capital-Related Costs
We proposed payment requirements for capital-related costs,
including the special exceptions payment, beginning October 1, 2001.
5. Proposed Changes for Hospitals and Hospital Units Excluded from the
Prospective Payment Systems
We discussed the following proposals concerning excluded hospitals
and hospital units and CAHs:
Limits on and adjustments to the proposed target amounts
for FY 2002.
Revision of the methodology for wage neutralizing the
hospital-specific target amounts using preclassified wage data.
Updated caps for new excluded hospitals and units as well
as changes
[[Page 39832]]
in the effective date of classifications of excluded hospitals and
units.
The prospective payment system for inpatient
rehabilitation hospitals and units.
Payments to CAHs, including exclusion from the payment
window requirements; the availability of CRNA pass-through payments;
payment for emergency room on-call physicians; treatment of ambulance
services; the use of certain qualified practitioners for preanesthesia
and postanesthesia evaluations; and clarification of location
requirements for CAHs.
6. Determining Prospective Payment Operating and Capital Rates and
Rate-of-Increase Limits
In the Addendum to the proposed rule, we set forth proposed changes
to the amounts and factors for determining the FY 2002 prospective
payment rates for operating costs and capital-related costs. We also
proposed threshold amounts for outlier cases. In addition, we proposed
update factors for determining the rate-of-increase limits for cost
reporting periods beginning in FY 2002 for hospitals and hospital units
excluded from the prospective payment system.
7. Impact Analysis
In Appendix A, we set forth an analysis of the impact of the
proposed changes on affected entities.
8. Capital Acquisition Model
In Appendix B of the proposed rule, we set forth the technical
appendix on the proposed FY 2002 capital cost model.
9. Report to Congress on the Update Factor for Hospitals under the
Prospective Payment System and Hospitals and Units Excluded From the
Prospective Payment System
In Appendix C of the proposed rule, as required by section
1886(e)(3) of the Act, we set forth our report to Congress on our
initial estimate of a recommended update factor for FY 2002 for
payments to hospitals included in the prospective payment systems, and
hospitals excluded from the prospective payment systems.
10. Recommendation of Update Factor for Hospital Inpatient Operating
Costs
In Appendix D, as required by sections 1886(e)(4) and (e)(5) of the
Act, we included our recommendation of the appropriate percentage
change for FY 2002 for the following:
Large urban area and other area average standardized
amounts (and hospital-specific rates applicable to SCHs and Medicare-
dependent, small rural hospitals) for hospital inpatient services paid
for under the prospective payment system for operating costs.
Target rate-of-increase limits to the allowable operating
costs of hospital inpatient services furnished by hospitals and
hospital units excluded from the prospective payment system.
11. Discussion of Medicare Payment Advisory Commission Recommendations
In the proposed rule, we discussed recommendations by the Medicare
Payment Advisory Commission (MedPAC) concerning hospital inpatient
payment policies 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. We respond to those
recommendations in section VII. of this preamble. For further
information relating specifically to the MedPAC March 1 report or to
obtain a copy of the report, contact MedPAC at (202) 653-7220 or visit
MedPAC's website at: www.medpac.gov.
12. Public Comments Received in Response to the May 4, 2001 Proposed
Rule
We received a total of 232 timely items of correspondence
containing multiple comments on the proposed rule. Major issues
addressed by the commenters included: additional payments for new
medical services and technologies, geographic reclassifications of
hospitals for purposes of the wage index, DRG reclassifications,
payments for GME, and payments to CAHs.
Summaries of the public comments received and our responses to
those comments are set forth below under the appropriate heading, with
the exception of comments and responses pertaining to specific payments
for new technologies under section 533 of Public Law 106-554. As
described previously, this provision will be implemented through a
separate final rule.
C. Summary of the Provisions of the August 1, 2000 Interim Final Rule
with Comment Period
On August 1, 2000, we published in the Federal Register (65 FR
47026) an interim final rule with comment period that implemented, or
conformed the regulations to, certain statutory provisions relating to
Medicare payments to hospitals for inpatient services that were
contained in Public Law 106-113, that were effective for FY 2000. The
following is a summary of the policy changes we implemented as a result
of Public Law 106-113:
1. Changes Relating to Payments for Operating Costs Under the Hospital
Inpatient Prospective Payment System
Reclassification of Certain Counties. We implemented the
provisions of section 152(a) of Public Law 106-113 that reclassified
hospitals in certain designated counties for purposes of making
payments to affected hospitals under section 1886(d) of the Act for FY
2000. The counties affected by this provision are identified under
section III. of this preamble.
Wage Index. We implemented sections 153 and 154 of Public
Law 106-113 that contain provisions affecting the wage indexes of
specific Metropolitan Statistical Areas (MSA). Under section 153, the
Hattiesburg, Mississippi FY 2000 wage index was calculated including
wage data from Wesley Medical Center. Under section 154, the Allentown-
Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was calculated
including wage data for Lehigh Valley Hospital.
Reclassification of Certain Urban Hospitals as Rural
Hospitals. We implemented section 401 of Public Law 106-113 which
directed the Secretary to treat certain hospitals located in urban
areas as being located in rural areas of their State if the hospital
meets statutory criteria and files an application with HCFA. This
provision was effective on January 1, 2000.
IME Adjustment. We implemented section 111 of Public Law
106-113 which provided for an additional payment to teaching hospitals
equal to the additional amount the hospitals would have been paid for
FY 2000 if the IME adjustment formula (which reflects the higher
indirect operating costs associated with GME) for FY 2000 had remained
the same as for FY 1999.
Extension of the MDH Provision. We implemented section 404
of Public Law 106-113 which extended the MDH program and its current
payment methodology for an additional 5 years, from FY 2002 through FY
2006.
2. Additional Changes Relating to Direct GME and IME
Initial Residency Period for Child Neurology Residency
Programs. We implemented section 312 of Public Law 106-113 which
provides that in determining the number of residents for purposes of
GME and IME payments, the period of board eligibility and the initial
residency period for child neurology is the period of board
[[Page 39833]]
eligibility for pediatrics plus 2 years. This provision is effective on
or after July 1, 2000, for residency programs that began before, on, or
after November 29, 1999.
Residents on Approved Leaves of Absence. We implemented
section 407(a) of Public Law 106-113 which provides that, for purposes
of determining a hospital's full-time equivalent (FTE) cap for direct
GME payments and the IME adjustment, a hospital may count an individual
to the extent that the individual would have been counted as a primary
care resident for purposes of the FTE cap but for the fact that the
individual was on maternity or disability leave or a similar approved
leave of absence. The provision relating to direct GME was effective
with cost reporting periods beginning on or after November 29, 1999.
The provision relating to the IME adjustment applied to discharges
occurring in cost reporting periods beginning on or after November 29,
1999.
Expansion of Number of Unweighted Residents in Rural
Hospitals. We implemented section 407(b) of Public Law 106-113 which
provides that a rural hospital's resident FTE count for direct GME and
IME may not exceed 130 percent of the number of unweighted residents
that the rural hospital counted in its most recent cost reporting
period ending on or before December 31, 1996. The provision relating to
direct GME applied to cost reporting periods beginning on or after
April 1, 2000. The provision relating to the IME adjustment applied to
discharges occurring on or after April 1, 2000.
Urban Hospitals with Rural Training Tracks or Integrated
Rural Tracks. We implemented section 407(c) of Public Law 106-113 which
allows an urban hospital that establishes separately accredited
approved medical residency training programs (or rural training tracks)
in a rural area or has an accredited training program with an
integrated rural track to receive an FTE cap adjustment for purposes of
direct GME and IME. The provision was effective with cost reporting
periods beginning on or after April 1, 2000, for direct GME, and with
discharges occurring on or after April 1, 2000, for IME.
Residents Training at Certain Veterans Affairs Hospitals.
We implemented section 407(d) of PublicLaw 106-113 which provides that
a non-Veterans Affairs (VA) hospital may receive a temporary adjustment
to its FTE cap to reflect residents who were training at a VA hospital
and were transferred on or after January 1, 1997, and before July 31,
1998, to the non-VA hospital because the program at the VA hospital
would lose its accreditation by the Accreditation Council on Graduate
Medical Education if the residents continued to train at the facility.
This provision applies as if it was included in the enactment of Public
Law 105-33, that is, for direct GME, with cost reporting periods
beginning on or after October 1, 1997, and for IME, for discharges
occurring on or after October 1, 1997. If a hospital is owed payments
as a result of this provision, payments must be made immediately.
3. Payments for Nursing and Allied Health Education: Utilization of
Medicare+Choice Enrollees
We implemented section 541 of Public Law 106-113 which provides an
additional payment to hospitals that receive payments under section
1861(v) of the Act for approved nursing and allied health education
programs associated with services to Medicare+Choice enrollees. This
provision is effective for portions of cost reporting periods occurring
on or after January 1, 2000.
4. Changes Relating to Hospitals and Hospital Units Excluded From the
Prospective Payment System
We implemented section 121 of Public Law 106-113 which amended
section 1886(b)(3)(H) of the Act to direct the Secretary to provide for
an appropriate wage adjustment to the caps on the target amounts for
psychiatric hospitals and units, rehabilitation hospitals and units,
and long-term care hospitals for cost reporting periods beginning on or
after October 1, 1999.
5. Changes Relating to CAHs
We implemented--
Section 401(b) of Public Law 106-113, which contained
conforming changes to incorporate the reclassifications made by section
401(a) of Public Law 106-113 to the CAH statute (section
1820(c)(2)(B)(i) of the Act). This provision is effective beginning on
January 1, 2000.
Section 403(a) of Public Law 106-113, which deleted the
96-hour length of stay restriction on inpatient care in a CAH and
authorized a period of stay that does not exceed, on an annual, average
basis, 96 hours per patient. This provision is effective beginning on
November 29, 1999.
Section 403(b) of Public Law 106-113, which allows for-
profit hospitals to qualify for CAH status. This provision is effective
beginning on November 29, 1999.
Section 403(c) of Public Law 106-113, which allows
hospitals that have closed within 10 years prior to November 29, 1999,
or hospitals that downsized to a health clinic or health center, to be
designated as CAHs if they satisfy the established criteria for
designation, other than the requirement for existing hospital status.
Section 403(e) of Public Law 106-113, which eliminated the
Medicare Part B deductible and coinsurance for clinical diagnostic
laboratory tests furnished by a CAH on an outpatient basis. This
provision is effective with respect to services furnished on or
afterNovember 29, 1999.
Section 403(f) of Public Law 106-113, entitled
``Participation in Swing Bed Program,'' which amended sections
1883(a)(1) and (c) of the Act.
6. Changes Relating Hospital to Swing Bed Program
We implemented section 408(a) of Public Law 106-113 which
eliminated the requirement for a hospital to obtain a certification of
need to use acute care beds as swing beds for skilled nursing facility
(SNF) level of care patients; and section 408(b) of Public Law 106-113
which eliminates constraints on the length of stay in swing beds for
rural hospitals with 50 to 100 beds. These provisions were effective on
the first day after the expiration of the transition period for
prospective payments for covered SNF services under the Medicare
program (that is, at the end of the transition period for the SNF
prospective payments system that began with the facility's first cost
reporting period beginning on or after July 1, 1998 and extend through
the end of the facility's third cost reporting period after this date).
We received a total of eight timely items of correspondence
containing multiple comments on the August 1, 2000 interim final rule
with comment period. Summaries of the public comments received and our
responses to those comments are set forth below under the appropriate
section headings of this final rule.
D. Summary of the Provisions of the June 13, 2001 Interim Final Rule
With Comment Period
On June 13, 2001, we published an interim final rule with comment
period in the Federal Register (66 FR 32172) that implemented changes
to the Act affecting Medicare payments to hospitals for inpatient
services that were made by Public Law 106-554. Some of these changes
were effective before the December 21, 2000 date of enactment of Public
Law 106-554, on April 1, 2001,
[[Page 39834]]
or on July 1, 2001. The changes, on which we requested public comment,
are as follows:
1. Changes Relating to Payments for Operating Costs Under the Hospital
Inpatient Prospective Payment System
Treatment of Rural and Small Urban Disproportionate Share
Hospitals (DSHs) . We implemented the provisions of section 211 of
Public Law 106-554 which lowered thresholds by which certain classes of
hospitals qualify for DSH payments, with respect to discharges
occurring on or after April 1, 2001.
Decrease in Reductions for DSH Payments. We implemented
section 303 of Public Law 106-554 which modified the previous reduction
in the DSH payment to be 2 percent in FY 2001 and 3 percent in FY 2002.
Medicare-Dependent, Small Rural Hospitals (MDHs). We
implemented section 212 of Public Law 106-554 which provided an option
to base eligibility for MDH status on discharges during two of the
three most recently audited cost reporting periods, effective with cost
reporting periods beginning on or after April 1, 2001.
Revision of Prospective Payment System Standardized
Amounts. We implemented section 301 of Public Law 106-554 which revised
the update factor increase for the inpatient prospective payment rates
for FY 2001.
Indirect Medical Education Adjustment (IME). We
implemented section 302 of Public Law 106-554 which provided that for
the purposes of making the IME payment for discharges occurring on or
after April 1, 2001 and before October 1, 2001, the adjustment will be
determined as if the adjustment equaled a 6.75 percent increase in
payment for every 10 percent increase in the resident-to-bed ratio,
rather than a 6.25 percent increase.
SCHs. We implemented section 213 of Public Law 106-554
which further extended the 1996 rebasing option, for hospital cost
reporting periods beginning October 1, 2000, to all SCHs and provides
that this extension is effective as if it had been included in section
405 of Public Law 106-113.
2. Payments for Nursing and Allied Health Education: Utilization of
Medicare+Choice Enrollees
We implemented section 512 of Public Law 106-554 which revised the
formula for determining the additional payment amounts to hospitals for
Medicare+Choice nursing and allied health education costs to
specifically account for each hospital's Medicare+Choice utilization.
3. Changes Relating to Payments for Capital-Related Costs Under the
Hospital Inpatient Prospective Payment System
As a result of implementing section 301 of Public Law 106-554,
which provided increased inpatient operating payment rates, we
recalculated the unified outlier threshold for inpatient operating and
inpatient capital-related costs. Therefore, we revised the capital
outlier offset which also required us to revise the capital-related
rates.
4. Changes Relating to Hospitals and Hospital Units Excluded From the
Prospective Payment System
Increase in the Incentive Payment for Excluded Psychiatric
Hospitals and Units. We implemented section 306 of Public Law 106-554,
which provided that for cost reporting periods beginning on or after
October 1, 2000, for psychiatric hospitals and units, if the allowable
net inpatient operating costs do not exceed the hospital's ceiling,
payment is the lower of: (1) net inpatient operating costs plus 15
percent of the difference between inpatient operating costs and the
ceiling; or, (2) net inpatient costs plus 3 percent of the ceiling.
Increase in the Wage Adjusted 75th Percentile Cap on the
Target Amounts for Long-Term Care Hospitals. We implemented section
307(a) of Public Law 106-554, which provided a 2-percent increase to
the wage-adjusted 75th percentile cap on the target amount for long-
term care hospitals, effective for cost reporting periods beginning
during FY 2001.
Increase in the Target Amounts for Long-Term Care
Hospitals. We implemented section 307(a) Public Law 106-554, which
provided a 25 percent increase to the target amounts for long-term care
hospitals for cost reporting periods beginning in FY 2001, up to the
cap on target amounts.
5. Changes Relating to CAHs
Elimination of Coinsurance for Clinical Diagnostic
Laboratory Tests Furnished by a CAH. We implemented section 201(a) of
Public Law 106-554, which amended section 1834(g) of the Act to state
that there will be no collection of coinsurance, deductible,
copayments, or any other type of cost sharing from Medicare
beneficiaries with respect to outpatient clinical diagnostic laboratory
services furnished as outpatient CAH services and that those services
will be paid for on a reasonable cost basis.
Assistance with Fee Schedule Payment for Professional
Services under All-Inclusive Rate. We implemented section 202 of Public
Law 106-554, which amended section 1834(g)(2)(B) of the Act to provide
that when a CAH elects to be paid for Medicare outpatient services
under the reasonable costs for facility services plus fee schedule
amounts for professional services method, Medicare will pay 115 percent
of the amount it otherwise pays for the professional services.
Condition of Participation with Hospital Requirements at
the Time of Application for CAH Designation (Sec. 485.612). We
implemented a conforming change to correct Sec. 485.612 to reflect that
certain entities are not required to have a provider agreement prior to
CAH designation.
6. Other Inpatient Costs
Increase in Reimbursement for Bad Debts. We implemented
section 541 of Public Law 106-554 which provided a 30 percent decrease
of allowable hospital bad debt reimbursement for cost reporting periods
beginning during FY 2001 and all subsequent fiscal years. This section
modified section 4451 of Public Law 105-33 that reduced the total
allowable bad debt reimbursement for hospitals by 45 percent.
We received a total of 13 timely pieces of correspondence
containing comments on the June 13, 2001 interim final rule with
comment period. A summary of these public comments and our responses to
them are set forth under sections IV. and VI. of this final rule.
II. Changes to DRG Classifications and Relative Weights
A. Background
Under the prospective payment system, we pay for inpatient hospital
services on a rate per discharge basis that varies according to the DRG
to which a beneficiary's stay is assigned. The formula used to
calculate payment for a specific case multiplies an individual
hospital's payment rate per case 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
[[Page 39835]]
in treatment patterns, technology, and any other factors that may
change the relative use of hospital resources. Changes to the DRG
classification system and the recalibration of the DRG weights for
discharges occurring on or after October 1, 2001 are discussed below.
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the prospective
payment system based on the principal diagnosis, up to eight additional
diagnoses, and up to six procedures performed during the stay, as well
as age, sex, and discharge status of the patient. The diagnosis and
procedure information is reported by the hospital using codes from the
International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM). Medicare fiscal intermediaries enter the
information into their claims processing systems and subject it to a
series of automated screens called the Medicare Code Editor (MCE).
These screens are designed to identify cases that require further
review before classification into a DRG.
After screening through the MCE and any further development of the
claims, cases are classified into the appropriate DRG by the Medicare
GROUPER software program. 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.
In version 18 of the GROUPER (used for FY 2001), cases are assigned
to one of 499 DRGs (including one DRG (469) for a diagnosis that is
invalid as a discharge diagnosis and one DRG (470) for ungroupable
diagnoses) in 25 major diagnostic categories (MDCs). Most MDCs are
based on a particular organ system of the body. For example, MDC 6 is
Diseases and Disorders of the Digestive System. However, some MDCs are
not constructed on this basis because 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 six DRGs to
which cases are directly assigned on the basis of procedure codes.
These are the DRGs for heart, liver, bone marrow, and lung transplants
(DRGs 103, 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 and
medical DRGs. Surgical DRGs are based on a hierarchy that orders
individual procedures or groups of procedures by resource intensity.
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, the 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 numerous changes to the DRG classification system for
FY 2002. The proposed changes, the public comments we received
concerning them, and the final DRG changes are set forth below. Unless
otherwise noted, the changes we are implementing will be effective in
the revised GROUPER software (Version 19.0) to be implemented for
discharges on or after October 1, 2001. Unless noted otherwise, we are
relying on the data analysis in the proposed rule for the changes
discussed here.
Chart 1 lists the changes we are making by adding new DRGs or
removing old DRGs. Chart 2 summarizes the changes we are making with
respect to the reassignment of procedure codes. Chart 3 presents the
changes we are making to the titles of existing DRGs.
In Chart 2 of the proposed rule, several procedure codes were
erroneously included in the ``Removed from DRG'' column of the chart
(66 FR 22650). The 11 affected codes are 37.21, 37.22, 37.23, 37.26,
88.52, 88.53, 88.54, 88.55, 88.56, 88.57, and 88.58. Inclusion of these
codes in this chart made it appear as if the codes were being deleted
from DRG 104. In fact, they are being additionally assigned to DRG 514.
We have corrected Chart 2 in this final rule.
Chart 1.--Summary of Changes in DRG Assignments
----------------------------------------------------------------------------------------------------------------
Diagnosis related groups (DRGs) Added as new Removed
----------------------------------------------------------------------------------------------------------------
Pre-MDC:
DRG 512 (Simultaneous Pancreas/Kidney Transplant)......................... X ...............
DRG 513 (Pancreas Transplants)............................................ X ...............
MDC 5 (Diseases and Disorders of the Circulatory System):
DRG 112 (Percutaneous Cardiovascular Procedures).......................... ............... X
DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization)...... X ...............
DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization)... X ...............
DRG 516 (Percutaneous Cardiovascular Procedures with Acute Myocardial X ...............
Infarction (AMI))........................................................
DRG 517 (Percutaneous Cardiovascular Procedures without AMI, with Coronary X ...............
Artery Stent Implant.....................................................
DRG 518 (Percutaneous Cardiovascular Procedures without AMI, without X ...............
Coronary Artery Stent Implant............................................
MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective
Tissue):
DRG 519 (Cervical Spinal Fusion with CC).................................. X ...............
DRG 520 (Cervical Spinal Fusion without CC)............................... X ...............
MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders):
DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other ............... X
Symptomatic Treatment with CC)...........................................
DRG 435 (Alcohol/Drug Abuse or Dependency, Detoxification or Other ............... X
Symptomatic Treatment without CC)........................................
DRG 436 (Alcohol/Drug Dependence with Rehabilitation Therapy)............. ............... X
DRG 437 (Alcohol/Drug Dependence, Combined Rehabilitation and ............... X
Detoxification Therapy)..................................................
DRG 521 (Alcohol/Drug Abuse or Dependence with CC)........................ X ...............
[[Page 39836]]
DRG 522 (Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation X ...............
Therapy).................................................................
DRG 523 (Alcohol/Drug Abuse or Dependence without CC, without X ...............
Rehabilitation Therapy)..................................................
----------------------------------------------------------------------------------------------------------------
Chart 2.--Summary of Assignment or Reassignment of Diagnosis or
Procedure Codes in Existing DRGs
------------------------------------------------------------------------
Diagnosis/procedure codes Removed from DRG Reassigned to DRG
------------------------------------------------------------------------
MDC 5 (Diseases and Disorders
of the CirculatorySystem)
------------------------------------------------------------------------
Principal Diagnosis Code:
410.01 Acute myocardial 116.............. 516.
infarction of
anterolateral wall,
initial episode of care.
410.11 Acute myocardial 116.............. 516.
infarction of other
anterior wall, initial
episode of care.
410.21 Acute myocardial 116.............. 516.
infarction of
inferolateral wall,
initial episode of care.
410.31 Acute myocardial 116.............. 516.
infarction of
inferoposterior wall,
initial episode of care.
410.41 Acute myocardial 116.............. 516.
infarction of other
inferior wall, initial
episode of care.
410.51 Acute myocardial 116.............. 516.
infarction of other
lateral wall, initial
episode of care.
410.61 True posterior wall 116.............. 516.
infarction, initial
episode of care.
410.71 Subendocardial 116.............. 516.
infarction, initial
episode of care.
410.81 Acute myocardial 116.............. 516.
infarction of other
specified sites, initial
episode of care.
410.91 Acute myocardial 116.............. 516
infarction of unspecified
site, initial episode of
care.
Procedure Codes:
37.94 Implantation or 104, 105......... 514, 515.
replacement of automatic
cardioverter/
defibrillation, total
system (AICD).
37.95 Implantation of 104, 105......... 514, 515.
automatic cardioverter/
defibrillator lead(s) only.
37.96 Implantation of 104, 105......... 514, 515.
automatic cardioverter/
defibrillator pulse
generator only.
37.97 Raplacement of 104, 105......... 514, 515.
automatic cardioverter/
defibrilator lead(s) only;.
37.98 Replacement of 104, 105......... 514, 515.
automatic cardioverter/
defibrillator pulse
generator only.
Operating Room Procedures:
35.96 Percutaneous 112, 116......... 516, 517, 518.
valvuloplasty.
36.01 Single vessel 112, 116......... 516, 517, 518.
percutaneous transluminal
coronary angioplasty
(PTCA) or coronary
atherectomy without
mention of thrombolytic
agent.
36.02 Single vessel 112, 116......... 516, 517, 518.
percutaneous transluminal
coronary angioplasty
(PTCA) or coronary
atherectomy with mention
of thrombolytic agent.
36.05 Multiple vessel 112, 116......... 516, 517, 518.
percutaneous transluminal
coronary angioplasty
(PTCA) or coronary
atherectomy performed
during the same operation,
with or without mention of
thrombolytic agent.
36.09 Other removal of 112, 116......... 516, 517, 518.
coronary artery
obstruction.
37.34 Catheter ablation of 112, 116......... 516, 517, 518.
lesion or tissues of heart.
92.27 Implantation or non-OR in MDC-5.. 517
insertion of radioactive
elements.
Nonoperating Room Procedures:
36.06 Insertion of 116.............. 517.
coronary artery stent(s).
37.26 Cardiac 112.............. 514, 516, 517, 518.
electrophysiologic
stimulation and recording
studies.
37.27 Cardiac mapping..... 112.............. 516, 517, 518.
------------------------------------------------------------------------
MDC 8 (Diseases and Disorders
of the Musculoskeletal System
and Connective Tissue)
------------------------------------------------------------------------
Procedure Codes:
81.02 Other cervical 497, 498......... 519, 520.
fusion, anterior technique.
81.03 Other cervical 497, 498......... 519, 520.
fusion, posterior
technique.
MDC 15 (Newborns and Other
Neonates with Conditions
Originating in the Perinatal
Period)
Diagnosis Codes:
770.7 Chronic respiratory 387, 389......... 92, 93.
disease arising in the
perinatal period.
773.0 Hemolytic disease 387, 389......... 390.
due to RH isoimmunization.
773.1 Hemolytic disease 387, 389......... 390.
due to ABO isoimmunization.
Secondary Diagnosis Codes:
478.1 Other diseases of 390.............. 391.
nasal cavity and sinuses.
520.6 Disturbances in 390.............. 391.
tooth eruption.
623.8 Other specified 390.............. 391.
noninflammatory disorders
of vagina.
709.00 Dyschromia, 390.............. 391.
unspecified.
709.01 Vitiglio........... 390.............. 391.
709.09 Dyschromia, Other.. 390.............. 391.
744.1 Accessory Auricle... 390.............. 391.
754.61 Congenital pes 390.............. 391.
planus.
757.33 Congenital 390.............. 391.
pigmentary anomalies of
skin.
757.39 Other specified 390.............. 391.
anomaly of skin.
764.08 ``Light for dates'' 390.............. 391.
without mention of fetal
malnutrition, 2,000-2,499
grams.
764.98 Fetal growth 390.............. 391.
retardation, unspecified,
2,000-2,499 grams.
772.6 Cutaneous hemorrhage 390.............. 391.
779.3 Feeding problems in 390.............. 391
newborns.
794.15 Abnormal and 390.............. 391.
auditory function studies.
[[Page 39837]]
796.4 Other abnormal 390.............. 391.
clinical findings.
V20.2 Routine infant or 390.............. 391.
child health check.
V72.1 Examination of ears 390.............. 391.
and hearing.
------------------------------------------------------------------------
Chart 3.--Summary of Retitled DRGs
--------------------------------------------------------------------------------------------------------------------------------------------------------
MDC DRG No. Current name New name
--------------------------------------------------------------------------------------------------------------------------------------------------------
MDC 5................................. DRG 116 Other Permanent Cardiac Other Cardiac Pacemaker Implantation.
Pacemaker Implantation,
or PTCA, with Coronary
Artery Stent Implant.
MDC 8................................. DRG 497 Spinal Fusion with CC.... Spinal Fusion except Cervical with CC.
MDC 8................................. DRG 498 Spinal Fusion without CC. Spinal Fusion except Cervical with CC.
--------------------------------------------------------------------------------------------------------------------------------------------------------
2. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Removal of Defibrillator Cases from DRGs 104 and 105
DRGs 104 (Cardiac Valve & Other Major Cardiothoracic Procedures
with Cardiac Catheterization) and 105 (Cardiac Valve & Other Major
Cardiothoracic Procedures without Cardiac Catheterization) include the
replacement or open repair of one or more of the four heart valves.
These valves may be diseased or damaged, resulting in either leakage or
restriction of blood flow to the heart, compromising the ability of the
heart to pump blood. This procedure requires the use of a heart-lung
bypass machine, as the heart must be stilled and opened to repair or
replace the valve.
Cardiac defibrillators are implanted to correct episodes of
fibrillation (very fast heart rate) caused by malfunction of the
conduction mechanism of the heart. Through implanted cardiac leads, the
defibrillator mechanism senses changes in heart rhythm. When very fast
heart rates occur, the defibrillator produces a burst of electric
current through the leads to restore the normal heart rate. An
implanted defibrillator constantly monitors heart rhythm. The
implantation of this device does not require the use of a heart-lung
bypass machine, and would be expected to be very different in terms of
resource usage, although both procedures currently group to DRGs 104
and 105.
For the proposed rule, as part of our ongoing review of DRGs, we
examined Medicare claims data on DRG 104 and DRG 105. We reviewed 100
percent of the FY 2000 MedPAR file containing hospital bills received
through May 31, 2000, for discharges in FY 2000, and found that the
average charges across all cases in DRG 104 were $84,060, while the
average charges across all cases in DRG 105 were $66,348. Carving out
code 37.94 (Implantation or replacement of automatic cardioverter/
defibrillator, total system [AICD]) from DRGs 104 and 105 increased
those average charges to $91,366 for DRG 104 and $67,323 for DRG 105.
We identified 11,021 defibrillator cases in DRG 104 (out of 25,112
total cases), with average charges of $74,719, and 2,434 defibrillator
cases in DRG 105 (out of 20,094 total cases), with average charges of
$59,267.
We performed additional review on cases containing code 37.95
(Implantation of automatic cardioverter/defibrillator lead(s) only)
with code 37.96 (Implantation of automatic cardioverter/defibrillator
pulse generator only) and on cases containing code 37.97 (Replacement
of automatic cardioverter/defibrillator lead(s) only) with code 37.98
(Replacement of automatic cardioverter/defibrillator pulse generator
only). This subgrouping contained only 56 patients. The average charges
for the 18 patients in DRG 104 were $58,847. The average charges for
the 38 patients in DRG 105 were $54,891.
In the proposed rule, because we believed the defibrillator cases
are significantly different from other cases in DRGs 104 and 105, we
proposed two new DRGs: DRG 514 (Cardiac Defibrillator Implant with
Cardiac Catheterization) and DRG 515 (Cardiac Defibrillator Implant
without Cardiac Catheterization).
We also proposed the removal of procedure codes 37.94, 37.95 and
37.96, and 37.97 and 37.98 from DRGs 104 and 105 to form the new DRGs
514 and 515.
We received 58 comments on this proposal.
Comment: Many commenters noted that implanted cardioverter
defibrillators (ICDs) or AICDs are lifesaving devices that demonstrate
state-of-the-art technology for the treatment of cardiac arrhythmias by
continuously monitoring, analyzing, and, if needed, restoring a
patient's normal heart rhythm.
One commenter described the technology. Similar to the size of a
pacemaker, the ICD is placed under the skin of the upper chest. It has
the capacity to continuously monitor and analyze a patient's heart
rhythm. If the ICD detects an arrhythmia, it can terminate the abnormal
rhythm with either a pacemaker function or the delivery of a low-energy
electrical shock to restore normal heart rhythm.
Response: We agree that ICDs and AICDs are an important addition to
the treatment of cardiac disease. The creation of DRGs 514 and 515 is
not meant to effect a judgement call about the efficacy or importance
of this treatment, but simply to attempt to improve the accuracy of
payments within MDC 5, based on the actual charge data associated with
these cases.
Comment: A vast majority of the commenters expressed concern that
payments associated with defibrillators will decrease for FY 2002 as a
result of this change, with some commenters noting that an ICD or AICD
may cost the hospital between $22,000 and $25,000 per device. The
commenters stated that if this is the case, there is a limited amount
for the remainder of the hospital care (for example, operating room,
supplies, nursing staff salary, and typically a 7-day stay in an
intensive care unit). Most commenters called for
[[Page 39838]]
additional analysis prior to implementation of DRGs 514 and 515.
Response: As we described in the proposed rule and above, DRGs 104
and 105 currently include many different procedures, with a range of
costs associated with these different procedures. We proposed to change
the assignment of cardiac defibrillators to new DRGs 514 and 515 to
more accurately pay for the more expensive procedures remaining in DRGs
104 and 105, as well as to improve the payment accuracy for cardiac
defibrillators. In fact, the relative weight of DRG 104 increases from
FY 2001 to FY 2002 by 9.1 percent.
Comment: Many commenters argued that using hospital charges to
determine DRG relative weights can give a distorted picture of the
costs of a procedure. The commenters referred to an unspecified
national database indicating that the average mark-up of charges over
cost for ICDs is lower than the mark-up applied to other components of
care. Other commenters referred to the March 2001 Report to Congress by
the MedPAC, which, in the context of evaluating available data for
setting accurate relative values, stated that hospitals' billed charges
``give a distorted picture of relative costliness across DRGs because
they reflect systematic differences among hospitals in the average
mark-up of charges over costs'' (page 11).
Several commenters stated that about 66 percent of hospitals are
losing $5,000 or more per case for these procedures. These commenters
did not understand why payment would be reduced even further in light
of those losses.
Response: Hospital charges have been the basis for recalibrating
the DRG relative weights since FY 1986 (see 50 FR 24372 and 50 FR
35652). To the extent that the mark-up of charges over costs varies
from one particular device or procedure to another, the relative
weights will be impacted. However, due to the relativity of the DRG
weights, a low mark-up associated with one device or procedure will be
offset by relatively higher mark-ups associated with another device or
procedure, leading to higher relative weights, and thus higher
payments, for the latter device or procedure. The prospective payment
system is an average-based payment methodology, where hospitals are
expected to offset any losses they may incur from any individual or
group of cases with payment gains incurred from other cases.
Furthermore, hospital charges are determined by each hospital on an
item-by-item basis. It is not possible to account for these individual
management decisions in the process of developing a national payment
system based on prospectively determined average payment rates.
As demonstrated in the impact analysis in Appendix A to this final
rule, hospital payments would rise (prior to the budget neutrality
adjustment) by 0.3 percent as a result of all of the DRG changes we are
implementing in this final rule, including this change. In addition, we
note that the latest analysis by MedPAC indicates the average hospital
Medicare inpatient operating margin during FY 1999 (the latest year
available) was 12.0 percent (Report to the Congress: Medicare Payment
Policy, page 64). Therefore, we believe that hospitals will be able to
adequately adjust to these payment changes in both the short and the
long term.
Comment: One commenter noted that the adjustment to DRGs 104 and
105 as reflected in Table 5, ``List of Diagnosis Related Groups (DRGs),
Relative Weighting Factors, Geometric and Arithmetic Mean Length of
Stay,'' in the Addendum of the proposed rule, does not reflect the
resource consumption as discussed above. The commenter recommended that
we increase the relative weights to reflect the resource consumption of
DRGs 104 and 105.
Response: In this final rule, the relative weight for DRG 104 is
7.8411 for FY 2002, an increase of 9.1 percent from FY 2001. The
relative weight for DRG 105 in this final rule is 5.6796 for FY 2002, a
0.4 percent increase from FY 2001. These percentage changes are very
similar to the percent change in average charges in DRGs 104 and 105
after removing ICD and AICD charges, as described above. We note that
the final relative weight values are based on 100 percent of FY 2000
discharges in the MedPAR database as of March 2001. The analysis using
average charges described above was based on an earlier sample of
cases; therefore, the percentage changes do not match exactly.
Comment: Other commenters noted that this change, and the resulting
increase in payments for procedures remaining in DRGs 104 and 105, is a
positive step to improving the payment for heart assist devices.
However, the commenters were disappointed that we did not take the
opportunity to make a similar revision for cases involving mechanical
heart assist devices.
Response: As described above, removing the ICDs/AICDs from DRGs 104
and 105 will have the net effect of increasing the relative weights for
both DRGs, so payment for the remaining cases will increase. We will
continue to evaluate our options for improving the accuracy of our
payments for heart assist technologies.
After carefully reviewing all of the comments submitted, we have
decided to proceed with the creation of two new DRGs to capture cases
involving the implantation of cardiac defibrillators. The new DRGs 514
and 515 include principal diagnosis codes and procedure codes as
reflected in Chart 4 below:
Chart 4.--Composition of New DRGs 514 and 515 in MDC 5
----------------------------------------------------------------------------------------------------------------
Included in DRG Included in DRG
Diagnosis and procedure codes 514 515
----------------------------------------------------------------------------------------------------------------
Principal Diagnosis Codes:
All of the principal diagnosis codes assigned to MDC-5.................... X X
Principal or Secondary Procedure Code:
37.94 Implantation or replacement of automatic cardioverter/ X X
defibrillator, total system (AICD).......................................
Combination Operating Procedure Codes:
37.95 Implantation of automatic cardioverter/defibrillator lead(s) only;
Plus
37.96 Implantation of automatic cardioverter/defibrillator pulse X X
generator only;..........................................................
Or
37.97 Replacement of automatic cardioverter/defibrillator lead(s) only;
Plus
37.98 Replacement of automatic cardioverter/defibrillator pulse generator X X
only.....................................................................
Plus: One of the Following Nonoperating Room ProcedureCodes:
37.21 Right heart cardiac catheterization................................ X
37.22 Left heart cardiac catheterization................................. X
[[Page 39839]]
37.23 Combined right and left heart cardiac catheterization.............. X
37.26 Cardiac electrophysiologic stimulation and recording studies....... X
88.52 Angiocardiography of right heart structures........................ X
88.53 Angiocardiography of left heart structures......................... X
88.54 Combined right and left heart angiocardiography.................... X
88.55 Coronary arteriography using a single catheter..................... X
88.56 Coronary arteriography using two catheters......................... X
88.57 Other and unspecified coronary arteriography....................... X
88.58 Negative-contrast cardiac roentgenography.......................... X
----------------------------------------------------------------------------------------------------------------
b. Percutaneous Cardiovascular Procedures
In the May 4 proposed rule, we indicated that we had reviewed other
DRGs within MDC 5 in order to determine if there were also logic
changes that could be made to these DRGs. The data were arrayed in a
variety of ways displaying myriad permutations, resulting in the
following proposed changes.
A percutaneous transluminal coronary angioplasty (PTCA) is an acute
intervention intended to minimize cardiac damage by restarting
circulation to the heart. Some patients with an acute myocardial
infarction (AMI) are now treated by performing a PTCA during the
hospitalization for the AMI. Currently, PTCAs with a coronary stent
implant are assigned to DRG 116 (Other Permanent Cardiac Pacemaker
Implantation, or PTCA with Coronary Artery Stent Implant), along with
pacemaker implants. The remaining percutaneous cardiovascular
procedures are assigned to DRG 112 (Percutaneous Cardiovascular
Procedures).
The volume of percutaneous cardiovascular procedures has grown
dramatically, with 186,669 cases identified in the FY 2000 MedPAR file
containing hospital bills submitted through May 31, 2000. Because of
the high volume, we decided to review the DRG for percutaneous
cardiovascular procedures. As a first step in the evaluation, we
combined the percutaneous cardiovascular procedures from DRGs 112 and
116. We then subdivided the combined percutaneous cardiovascular
procedure group into two groups based on the principal diagnosis (Pdx)
of AMI.
------------------------------------------------------------------------
Average
Group Count charge
------------------------------------------------------------------------
With Pdx of AMI................................... 50,442 $31,722
Without Pdx of AMI................................ 136,227 23,989
------------------------------------------------------------------------
Each of these groups was further evaluated by subdividing them
based on whether a coronary stent was implanted. The vast majority of
patients with an AMI had a coronary stent implanted. Patients without
an AMI were subdivided into two groups based on whether a coronary
stent was implemented.
------------------------------------------------------------------------
Average
Group Count charge
------------------------------------------------------------------------
Without Pdx of AMI with stent..................... 111,441 $24,745
Without Pdx of AMI without stent.................. 24,786 20,589
------------------------------------------------------------------------
In the proposed rule, based on this analysis, we proposed the
removal of PTCAs with coronary artery stent from DRG 116, thus limiting
DRG 116 to permanent cardiac pacemaker implantation. This removal would
leave approximately 68,000 non-PTCA cases in DRG 116.
In conjunction with this evaluation, we considered a new
technology, intravascular brachytherapy, that is being used to treat
coronary in-stent stenosis. A gamma-radiation-impregnated tape is
threaded through the affected vessel for a specified amount of dwell
time, and then the tape is removed. Intravascular brachytherapy was
approved by the Food and Drug Administration in November 2000.
Intravascular brachytherapy is assigned to procedure code 92.27
(Implantation or insert of radioactive elements). With the use of
angioplasty, these cases are currently assigned to DRG 112
(Percutaneous Cardiovascular Procedures). Therefore, cases involving
this new technology will be implicated by these changes.
Also in the proposed rule, we proposed to retitle DRG 116 ``Other
Cardiac Pacemaker Implantation,'' remove DRG 112, and create three new
DRGs: DRG 516 (Percutaneous Cardiovascular Procedures with Acute
Myocardial Infarction (AMI)); DRG 517 (Percutaneous Cardiovascular
Procedures without AMI, with Coronary Artery Stent Implant); and DRG
518 (Percutaneous Cardiovascular Procedures without AMI, without
Coronary Artery Stent Implant). In order to be assigned to new DRG 516,
cases must contain one of the principal diagnoses plus the operating
room procedures listed in Chart 5. Because DRG 516 contains acute
myocardial infarction, which is hierarchically ordered before DRGs 517
and 518, any AMI cases also containing codes 92.27 or 36.06 (Insertion
of coronary artery stents(s)) would automatically be assigned to DRG
516. We also proposed the assignment of patients with a percutaneous
cardiovascular procedure and intravascular radiation treatment to new
DRG 517. As more data become available, we will reassess the assignment
of intravascular radiation treatment to DRG 517. New DRG 518 would
contain the same operating room and nonoperating room procedures as new
DRG 517, with the exception of codes 92.27 and 36.06. We received 10
comments on this proposal.
Comment: Several commenters supported the reclassification of
percutaneous vascular procedures to DRGs within this MDC. Other
commenters, however, stated the proposed changes would be inappropriate
because they would reduce payment overall for percutaneous
cardiovascular procedures. These commenters noted that new technologies
associated with these procedures are, in fact, more costly rather than
less costly. In addition, commenters expressed concern that payment for
pacemakers under DRG 116 would be reduced from FY 2001 levels.
Response: Based on 100 percent of FY 2000 discharges on file
through March 2001, we estimate the case-weighted average relative
weight for DRGs 116, 516, 517 and 518 to be 2.2236, a 4.5 percent
decline from the case-weighted average relative weight for DRGs 112 and
116 for FY 2001 (2.3280). As discussed above in relation to the new
DRGs 514 and 515, the calculation of
[[Page 39840]]
the relative weights reflects the charges submitted by hospitals for
these cases.
Comment: Five commenters addressed only the inclusion of code 92.27
(Implantation or insertion of radioactive elements, also known as
brachytherapy) in new DRG 517 in cases without presence of AMI (these
cases would go to DRG 516 if AMI were present). Four of the five
expressed appreciation for this change, citing its clinical
appropriateness and increased payment, which is close to the additional
facility costs for performing the procedure.
One commenter, while commending the decision to assign these cases
to DRG 517, requested clarification about our decisionmaking process in
assigning this technology to the same DRG as coronary stents. The
commenter requested that we outline the specific criteria we applied or
the process we followed to evaluate the adequacy of the external data
submitted.
Response: Although we received external data from a manufacturer of
this technology, they were not the basis for our decision, as we were
unable to verify the data because the data were submitted too late in
the process of preparing the FY 2002 proposed rule. When we proposed to
restructure DRGs 112 and 116, our decision was based on the clinical
coherence of the DRGs. Intravascular radiation treatment is an invasive
procedure that requires an additional 35 to 45 minutes, and requires
the services of both a radiation (nuclear) physicist and a radiation
safety officer in the operating room, as well as specifically trained
operating room personnel, such as an ultrasound specialist.
Comment: One commenter wrote that these changes fail to account for
the use of GP IIB-IIIA inhibitors for cases with acute coronary
syndromes. The commenter was concerned whether the DRG assignment for
these cases under the proposed DRGs would be appropriate.
Response: The administration of GP IIB-IIIA inhibitors is through
intravenous infusion, and is assigned to code 99.20 (Injection or
infusion of platelet inhibitor). The GROUPER does not recognize code
99.20 as a procedure and, therefore, its presence does not affect DRG
assignment. As described above, the DRG assignment for these cases
under the newly configured DRGs 116, 516, 517, and 518 would be
determined by the presence of AMI and the presence of other procedures
that would cause the case to group to one of the other DRGs besides
518. Our analysis of FY 2000 MedPAR data indicates that, among cases
with code 99.20 currently assigned to either DRGs 112 or 116 for FY
2000, the majority of these cases are currently assigned to DRG 116
(317,108 discharges compared to 52,945). Therefore, the majority of
these cases involve procedures that do affect DRG assignment. We will
continue to evaluate these cases, however, to determine whether further
revisions would be appropriate.
Comment: One commenter indicated that codes 37.27 (Cardiac mapping)
and 37.34 (Catheter ablation of lesion or tissues of heart) would now
be grouped to new DRGs 516, 517, and 518. Because these procedures are
not usually used on patients with AMI or patients who receive a stent,
the commenter indicated the cases would most likely be grouped to DRG
518. The commenter believed that we were unaware that certain
procedures, such as the two previously mentioned, have greater resource
utilization than other percutaneous cardiovascular procedures that do
not involve AMI or stents. The commenter asserted that this is an
inadvertently inappropriate classification. The commenter recommended
that CMS either create a separate DRG for cardiac mapping and ablation
procedures, or else assign codes 37.27 and 37.34 to DRG 516 after
retitling the DRG appropriately.
Response: These cases previously were assigned to either DRG 112 or
116, depending upon whether they involved the insertion of a stent or
the implantation of a pacemaker. This GROUPER assignment logic did not
change, although the presence or absence of AMI is now a factor as
well. We believe this is an appropriate clinical categorization.
However, we will consider this issue as we continue to evaluate these
DRGs.
The principal diagnosis codes and operating room and nonoperating
room procedure codes that are included in the new DRGs 516, 517, and
518 are reflected in Chart 5.
Chart 5.--Composition of New DRGs 516, 517, and 518 in MDC 5
----------------------------------------------------------------------------------------------------------------
Included in Included in Included in
Diagnosis and procedure codes DRG 516 DRG 517 DRG 518
----------------------------------------------------------------------------------------------------------------
Principal Diagnosis Codes:
410.01 Acute myocardial infarction of anterolateral X ............... ...............
wall, initial episode of care...........................
410.11 Acute myocardial infarction of other anterior X ............... ...............
wall, initial episode of care...........................
410.21 Acute myocardial infarction of inferolateral X ............... ...............
wall, initial episode of care...........................
410.31 Acute myocardial infarction of inferoposterior X ............... ...............
wall, initial episode of care...........................
410.41 Acute myocardial infarction of other inferior X ............... ...............
wall, initial episode of care...........................
410.51 Acute myocardial infarction of other lateral X ............... ...............
wall, initial episode of care...........................
410.61 True posterior wall infarction, initial episode X ............... ...............
of care.................................................
410.71 Subendocardial infarction, initial episode of X ............... ...............
care....................................................
410.81 Acute myocardial infarction of other specified X ............... ...............
sites, initial episode of care..........................
410.91 Acute myocardial infarction of unspecified site, X ............... ...............
initial episode of care.................................
Plus:
Operating Room Procedures:
35.96 Percutaneous valvuloplasty....................... X X X
And
36.01 Single vessel percutaneous transluminal coronary X X X
angioplasty (PTCA) or coronary atherectomy without
mention of thrombolytic agent...........................
Or
36.02 Single vessel percutaneous transluminal coronary X X X
angioplasty (PTCA) or coronary atherectomy with mention
of thrombolytic agent...................................
Or
36.05 Multiple vessel percutaneous transluminal X X X
coronary angioplasty (PTCA) or coronary atherectomy
performed during the same operation, with or without
mention of thrombolytic agent...........................
[[Page 39841]]
And
36.09 Other removal of coronary artery obstruction..... X X X
And
37.34 Catheter ablation of lesion or tissues of heart.. X X X
92.27 Implantation or insertion of radioactive elements ............... X ...............
Or:
Nonoperating Room Procedures:
36.06 Insertion of coronary artery stent(s)............ ............... X ...............
37.26 Cardiac electrophysiologic stimulation and X X X
recording studies.......................................
37.27 Cardiac mapping.................................. X X X
----------------------------------------------------------------------------------------------------------------
DRG 121 (Circulatory Disorders with AMI and Major Complication,
Discharged Alive), DRG 122 (Circulatory Disorders with AMI without
Major Complication, Discharged Alive), and DRG 123 (Circulatory
Disorders with AMI, Expired) are not affected by these changes.
c. Removal of Heart Assist Systems
The ICD-9-CM Coordination and Maintenance Committee considered the
nonoperative removal of heart assist systems at its November 17, 2000
meeting. A device called the intra-aortic balloon pump (IABP) is one of
the most common types of ventricular assist systems. A balloon catheter
is placed into the patient's descending thoracic aorta, and inflates
and deflates with each heartbeat. This device is timed with the
patient's own heart rhythm, and inflates and circulates blood to the
heart and other organs. This allows the heart to rest and recover. The
IABP may be used preoperatively, intraoperatively, or postoperatively.
It supports the patient from a few hours to several days.
Code 37.64 (Removal of heart assist system) already exists, and it
is considered by the GROUPER to be an operative procedure. However, the
nonoperative removal of a heart assist system can be done at the
patient's bedside, is noninvasive, and requires no anesthesia.
Therefore, the Committee created code 97.44 (Nonoperative removal of
heart assist system) for use with discharges beginning on or after
October 1, 2001.
In the past, we have assigned new ICD-9-CM codes to the same DRG to
which the predecessor code was assigned. In the proposed rule, we
explained that if this practice were to be followed, we would have
proposed that code 97.44 be assigned to MDC 5, DRGs 478 (Other Vascular
Procedures with CC) and 479 (Other Vascular Procedures without CC).
After hospital charge data became available, we would have considered
moving it to other DRGs. However, in accordance with section 533(a) of
Public Law 106-554, which requires a more expeditious technique of
recognizing new medical services or technology for the hospital
inpatient prospective payment system, we will reconsider this
longstanding practice when possible. Therefore, as code 97.44 was
designed to capture heart assist system removal that is clearly
nonoperative, we did not propose to designate 97.44 as a code which the
GROUPER recognizes as a procedure. The GROUPER will assign these cases
to a medical DRG based on the principal diagnosis, or to a surgical DRG
if a surgical procedure recognized by the GROUPER is performed. This
assignment can be found in Table 6B, New Procedure Codes, in the
Addendum to this rule.
We received no comments on this proposal. However, we did receive
comments on another issue in MDC 5, relating to DRGs 110 and 111 (Major
Cardiovascular Procedures with and without CC).
Comment: One commenter submitted a case study on stent technology,
noting that Medicare payments in their facility were 31.4 percent lower
than total costs. This commenter made no recommendations, but stated
that often surgeons must use additional stent segments to repair
aneurysms, increasing total costs by thousands of dollars.
Response: We do not have a clear understanding of the commenter's
statement that often surgeons must use additional stent segments to
repair aneurysms, thereby increasing total costs. We are unclear
because the device presented to us for new ICD-9-CM code consideration
was proposed as a single device, custom-fitted to the patient's needs.
We will continue to monitor this technology and the new code (used for
discharges on or after October 1, 2001).
Comment: One commenter noted that aortic endografts are assigned to
DRGs 110 and 111, and the cost of the device alone is greater than the
entire payment for DRG 111. The commenter noted that this is a
straightforward issue, and recommended that these cases be assigned
specifically to DRG 110.
Response: DRGs 110 and 111 are what we refer to as paired DRGs.
Paired DRGs are exactly the same as each other with regard to the
principal diagnosis and procedure codes in most cases. However, other
aspects of the patient's case have a bearing on DRG assignment, such as
the patient's age or the secondary diagnoses (which determine
comorbidities or complications in appropriate DRGs). In this case, DRGs
110 and 111 are divided based on the presence or absence of secondary
diagnosis codes. If there are no secondary diagnosis codes present, the
case will be assigned to DRG 111. It has been our experience that
patients not having secondary diagnoses are less expensive for the
hospital to treat, thereby resulting in a lower weighted DRG
assignment.
Hospitals should code their records completely, recording and
submitting all relevant diagnosis and procedure codes having a bearing
on the current admission. As noted previously, payment for each DRG is
based on the average charges for cases assigned to that DRG as
submitted to us by hospitals.
3. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
a. Refusions
We have received questions from correspondents regarding the
appropriateness of the spinal fusion DRGs: DRG 496 (Combined Anterior/
Posterior Spinal Fusion); DRG 497 (Spinal Fusion with CC); and DRG 498
(Spinal Fusion without CC). Several correspondents expressed concern
about the inclusion of all refusions of the spine into one procedure
code, 81.09 (Refusion of spine, any level or technique). The
correspondents pointed out that because all refusions using any
technique or level are in this one code,
[[Page 39842]]
all of these cases are assigned to DRG 497 and DRG 498. They also
pointed out that fusion cases involving both an anterior and posterior
technique are assigned to DRG 496. Although cases with the refusion
code that involve anterior and posterior techniques would appear to be
more appropriately assigned to DRG 496, this is not the case.
We recognized this limitation in the refusion codes and further
acknowledged that this limitation in the ICD-9-CM coding system creates
DRG problems by preventing the assignment to DRG 496 even when both
anterior and posterior techniques are used for refusion cases.
Therefore, we referred the issue to the ICD-9-CM Coordination and
Maintenance Committee and requested the Committee to consider code
revisions for the refusions of the spine during its year 2000 public
meetings.
After its deliberations, the Committee approved a series of new
procedure codes for refusion of the spine that could lead to
improvements within DRGs 497 and 498. These new codes, listed below, go
into effect on October 1, 2001.
81.30 Refusion of spine, not otherwise specified
81.31 Refusion of atlas-axis spine
81.32 Refusion of other cervical spine, anterior technique
81.33 Refusion of other cervical spine, posterior technique
81.34 Refusion of dorsal and dorsolumbar spine, anterior technique
81.35 Refusion of dorsal and dorsolumbar spine, posterior technique
81.36 Refusion of lumbar and lumbosacral spine, anterior technique
81.37 Refusion of lumbar and lumbosacral spine, lateral transverse
process technique
81.38 Refusion of lumbar and lumbosacral spine, posterior technique
81.39 Refusion of spine, not elsewhere classified
As previously stated, all refusions of the spine and corrections of
the pseudarthrosis of the spine are assigned to code 81.09. Code 81.09,
which is always assigned to DRG 497 or DRG 498, includes refusions at
any level of the spine using any technique. With the creation of the
new procedure codes listed above, it will be possible to determine the
level of the spine at which the refusion is performed, as well as the
technique used, and assign the case to a more appropriate DRG.
These new procedure codes should greatly improve our ability to
determine the level and technique used in the refusion.
In the past, we have assigned new ICD-9-CM codes to the same DRG to
which the predecessor code was assigned. In the proposed rule, we
explained that if this practice were followed, these new codes would
have been assigned to DRG 497 and 498 as they are currently. After data
became available, we would have considered moving them to other DRGs.
However, in accordance with section 533(a) of Public Law 106-554, which
requires more expeditious methods of recognizing new medical services
or technology under the inpatient hospital prospective payment system,
we will reconsider this longstanding practice when possible. Since the
new codes clearly allow us to identify cases where the technique was
either anterior or posterior and these cases are clinically similar
and, therefore, should be handled in the same fashion, we proposed to
immediately assign these cases on the same basis as the fusion codes
(81.00 through 81.09). We would not wait for actual claims data before
making this change. These assignments are reflected in Chart 6 and also
can be found in Table 6B, in section V. of the Addendum to this final
rule.
Comment: One commenter supported the creation of the ICD-9-CM codes
for refusions as well as their proposed DRG assignments.
Response: We appreciate the support of the commenter and are
adopting the proposed DRG assignments for refusions of spine as final.
b. Fusion of Cervical Spine
In the proposed rule we discussed an inquiry concerning the spinal
DRGs that focused on fusions of the cervical spine. The inquirer stated
that there was a significant difference between inpatients who undergo
anterior cervical spinal fusion and other types of spinal fusion in
regard to treatment, recovery time, costs, and risk of complications.
Anterior cervical spinal fusions are assigned to procedure code 81.02
(Other cervical fusion, anterior technique). The inquirer pointed out
that anterior cervical fusions differ significantly from anterior
techniques at other levels since the anatomic approach is far less
invasive. Thoracic anterior techniques require working around the
cardiac and respiratory systems in the chest cavity, while lumbar
anterior techniques require working around bowel and digestive system
and the abdominal muscles. The inquirer recommended that code 81.02 be
removed from DRGs 497 and 498 and grouped separately.
We analyzed claims data from the FY 2000 MedPAR file containing
hospital bills received through May 31, 2000, and confirmed that
charges are lower for fusions of the cervical spine than fusions of the
thoracic and lumbar spine. This was true for both anterior and
posterior cervical fusions of the spine. Our medical consultants agree
that the data and their clinical analysis support the creation of new
DRGs for cervical fusions of the spine. We proposed to remove procedure
codes 81.02 and 81.03 from the spinal fusion DRGs (currently, DRGs 497
and 498) and assign them to new DRGs for cervical spinal fusion with
and without CC. We also proposed four groupings for fusion DRGs. The
net effect of this change is an increase in the weights for DRGs 497
and 498, since the lower charges for the cervical fusions would be
removed. The average standardized charge for all spinal fusions with
CCs was $26,957. For all spinal fusions without CCs, the average charge
was $16,492. The table below also shows average standardized charges
for these types of cases before and after the revisions.
------------------------------------------------------------------------
Average Average charge
Revised spinal fusion DRGs charge before after
revisions revisions
------------------------------------------------------------------------
DRG 497 Spinal Fusion Except Cervical $26,957 $36,821
with CC................................
DRG 498 Spinal Fusion Except Cervical 17,492 26,297
without CC.............................
DRG 519 Cervical Spinal Fusion with CC.. .............. 26,957
DRG 520 Cervical Spinal Fusion without .............. 16,492
CC.....................................
------------------------------------------------------------------------
[[Page 39843]]
Based on the groupings, we proposed the creation of two new DRGs:
DRG 519 (Cervical Spinal Fusion with CC); and DRG 520 (Cervical Spinal
Fusion without CC). The procedure codes that would be included in the
DRGs 519 and 520 are reflected in Chart 6 below.
We also proposed to add the new ICD-9-CM procedure codes for
refusion of the cervical spine (81.32 and 81.33) to the new cervical
spine fusion DRGs because they are clinically similar.
In addition, we proposed to retitle DRG 497 ``Spinal Fusion Except
Cervical with CC'' and DRG 498 ``Spinal Fusion Except Cervical without
CC.'' The retitled DRGs 497 and 498 would retain fusion codes 81.00,
81.01, and 81.04 through 81.08 and include the new refusion codes
81.30, 81.31, and 81.34 through 81.39, as reflected in Chart 6 below.
Comment: One commenter commended the creation of the new ICD-9-CM
codes for spinal refusions and the development of the new DRGs for
cervical fusions. This commenter, a manufacturer of devices used for
spinal fusions, agreed that cervical fusions on average cost less than
lumbar and thoracic fusions. Another commenter who supported the
creation of the new DRGs mentioned that this classification would more
appropriately reflect the resources used in the varying cases.
Two commenters asserted that DRGs 497 and 498 fail to take into
account the cost variations when multi-level spinal fusions are
performed. The commenters stated that the cost and complexity of a
discharge varies substantially depending on the number of levels
performed as part of a fusion procedure. Commenters recommended that
new ICD-9-CM procedure codes be created for multi-level spine
procedures to track and measure costs. The current ICD-9-CM codes do
not differentiate between the number of levels that are fused. The
commenter defined multi-level as three or more vertebral segments,
either anterior or posterior, or both. In addition, the commenter
recommended that these new multi-level fusion codes be assigned to the
higher weighted DRG 496. The commenter recommended that DRG 496 be
renamed ``Multi-Level Spine Procedure Anterior and/or Posterior for
Stabilization and/or Correction and/or Refusion.''
Response: We agree that the current ICD-9-CM procedure codes do not
differentiate between the number of levels fused. This proposal will be
addressed by the ICD-9-CM Coordination and Maintenance Committee at its
November 1, 2001 meeting. A potential problem with this recommendation
will be the need to avoid overlapping codes. The current fusion codes
are based on an axis of the level of the fusion (cervical or lumbar)
and an additional axis of the approach (anterior, posterior, or lateral
transverse). Devising a modified or additional scheme that utilizes an
additional axis of the number of disks fused may be quite challenging.
If this scheme requires the use of a set of codes from the new Chapter
17, we could quickly use up these currently empty codes. As far as the
recommendation to include these new multi-level fusion codes in DRG
496, this issue will be deferred until after the coding issue is
addressed. If new codes are created, they will be included in an
upcoming proposed rule along with their proposed DRG assignment.
Since there was support for the proposed changes to the spinal
DRGs, these will be implemented as final changes effective October 1,
2001.
c. Posterior Spinal Fusion
We received other correspondence regarding the current DRG
assignment for code 81.07, Lumbar and lumbosacral fusion, lateral
transverse process technique. The correspondent stated that physicians
consider code 81.07 to be a posterior procedure. The patient is placed
prone on the operating table and the spine is exposed through a
vertical midline incision. The correspondent pointed out that code
81.07 is not classified as a posterior procedure within DRG 496
(Combined Anterior/Posterior Spinal Fusion). Therefore, when 81.07 is
reported with one of the anterior techniques fusion codes, it is not
assigned to DRG 496. The correspondent recommended that code 81.07 be
added to the list of posterior spinal fusion codes for use in
determining assignment to DRG 496.
In the proposed rule, we indicated that we consulted with our
clinical advisors and they agreed that this addition should be made.
Since we proposed to handle the new refusion codes in the same manner
as the fusion codes, we also proposed to assign DRG 496 when 81.37 is
used with one of the anterior technique fusion or refusion codes. This
would be similar to the manner in which code 81.07 is classified. For
assignment to DRG 496, we would consider codes 81.02, 81.04, 81.06,
81.32, 81.34, and 81.36 to be anterior techniques and codes 81.03,
81.05, 81.07, 81.08, 81.33, 81.35, and 81.38 to be posterior
techniques.
Chart 6.--Revised Composition of DRGS 496, 497, and 498 and Composition of DRG 519 and 520 in MDC 8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Existing DRG 496
-------------------------------- Retained in Retained in Included in
Diagnosis and procedure codes Assigned as Assigned as or Added to or Added to DRG 519
anterior posterior existing DRG existing DRG included in
techniques techniques 497 498 DRG 520
-----------------------------------------------------------------------------------------------------------------------------------------
Principal or Secondary Procedure Codes:
81.00 Spinal fusion, not otherwise specified....... .............. .............. X X .............. ..............
81.01 Atlas-axis fusion............................ .............. .............. X X .............. ..............
81.02 Other cervical fusion, anterior technique.... X .............. .............. .............. X X
81.03 Other cervical fusion, posterior technique... .............. X .............. .............. X X
81.04 Lumbar and lumbosacral fusion, anterior X .............. X X .............. ..............
technique..........................................
81.05 Lumbar and lumbosacral fusion, posterior .............. X X X .............. ..............
technique..........................................
81.06 Lumbar and lumbosacral fusion, anterior X .............. X X .............. ..............
technique..........................................
81.07 Lumbar and lumbosacral fusion, lateral .............. X X X .............. ..............
transverse process technique.......................
81.08 Lumbar and lumbosacral fusion, posterior .............. X X X .............. ..............
technique..........................................
[[Page 39844]]
81.30 Refusion of spine, not otherwise specified... .............. .............. X X .............. ..............
81.31 Refusion of atlas-axis spine................. .............. .............. X X .............. ..............
81.32 Refusion of other cervical spine, anterior X .............. .............. .............. X X
technique..........................................
81.33 Refusion of other cervical spine, posterior .............. X .............. .............. X X
technique..........................................
81.34 Refusion of dorsal and dorsolumbar spine, X .............. X X .............. ..............
anterior technique.................................
81.35 Refusion of dorsal and dorsolumbar spine, .............. X X X .............. ..............
posterior technique................................
81.36 Refusion of lumbar and lumbosacral spine, X .............. X X .............. ..............
anterior technique.................................
81.37 Refusion of lumbar and lumbosacral spine, .............. X X X .............. ..............
posterior technique................................
81.38 Refusion of lumbar and lumbosacral spine, .............. X X X .............. ..............
posterior technique................................
81.39 Refusion of spine, not elsewhere classified.. .............. .............. X X .............. ..............
--------------------------------------------------------------------------------------------------------------------------------------------------------
There was no opposition expressed to the changes proposed for
posterior spinal fusions; therefore, we are adopting the proposed
changes as final.
d. Spinal Surgery
The California Division of Workers' Compensation notified us of a
possible problem with the following spinal DRGs:
DRG 496 (Combined Anterior/Posterior Spinal Fusion)
DRG 497 (Spinal Fusion with CC)
DRG 498 (Spinal Fusion without CC)
DRG 499 (Back & Neck Procedures except Spinal Fusion with CC)
DRG 500 (Back & Neck Procedures except Spinal Fusion without CC)
The Division of Workers' Compensation uses the DRG categories
developed by CMS to classify types of hospital care. However, instead
of using CMS' weights for determining reimbursement for inpatient
services, the Division sets a global fee for all inpatient medical
services not otherwise exempted. This fee is established by multiplying
the product of the DRG weight (or revised DRG weight for a small number
of categories) and the health facility's composite factor by 1.20 to
get the maximum amount for worker compensation admissions.
The Division of Workers' Compensation has received reports that the
formula it uses for reimbursing cases may be providing inadequate
reimbursement. California hospitals and orthopedists have reported that
certain spinal surgery DRGs (DRGs 496 through 500) may involve
different types of care and/or technologies than those in use at the
time these groups were formulated. Health care providers in California
report ``recent increased use of the new implantation devices,
hardware, and instrumentation, coupled with requirements for intensive
hospital services accompanying use of new procedures, has led to
inadequate reimbursement in these DRGs.'' As a short-term response to
these concerns, the California Division of Workers' Compensation is
exempting the costs of hardware and instrumentation from the global fee
of the fee schedule for DRGs 496 through 500. The Division also
requested that CMS examine these DRGs for any potential problem under
the Medicare reimbursement system.
The ICD-9-CM coding system does not capture specific types of
implantation devices, hardware, and instrumentation. Therefore, we were
not able to verify the claim that these new devices have led to
increased costs in specific cases. We believe that the adoption of a
more detailed coding system, such as ICD-10-PCS, would supply greater
amounts of detail on these items. However, in the short term, it is not
possible to identify a specific problem that involves implantation
devices, hardware, and instrumentation.
Comment: As previously stated, we received support for the proposed
changes to the spinal fusion DRGs. As was also stated, one commenter
pointed out that the current ICD-9-CM codes do not specify the number
of levels fused, nor do they specify the types of devices used.
One commenter, who manufactures spinal fusion devices, commended
the new ICD-9-CM codes for refusions and the new DRGs for cervical
fusions. This commenter also requested new codes specifying the number
of levels fused. The commenter stated that typically two devices are
used per level and therefore, with increased levels, there would be an
increase in the number of infusion devices. The commenter recommended
new codes for multi-level spinal fusions, but did not recommend new
codes that would specify particular types of devices.
Responses: This coding issue will be addressed at future meetings
of the ICD-9-CM Coordination and Maintenance Committee. If new codes
are created, their DRG assignment would be addressed in a subsequent
proposed rule.
4. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)
We have received correspondence from a manufacturer of an
implantable vascular device requesting that code 86.07 (Insertion of
totally implantable vascular access device [VAD]) be assigned as an
operative procedure in MDC 11, to DRG 315 (Other Kidney & Urinary Tract
O.R. Procedures). This request was inadvertently omitted from the May
4, 2001 proposed rule. Therefore, we are taking this opportunity to
discuss possible designation of this procedure code as a code affecting
DRG assignment in MDC 11.
[[Page 39845]]
Procedure code 86.07 describes the implantation of a VAD into the
chest wall and blood vessels of a patient's upper body. Patients
requiring this particular device have been diagnosed with renal
(kidney) failure. Insertion of a VAD allows access to the patient's
blood for dialysis purposes when other sites for hemodialysis have been
exhausted. According to representatives from the manufacturer of one
particular VAD used for hemodialysis, this device costs the hospitals
$1,750, and is usually inserted in the outpatient setting as opposed to
admission for insertion of the device.
The GROUPER program does not recognize code 86.07 as a procedure in
other than MDC 9 (Disease and Disorders of the Skin, Subcutaneous
Tissue and Breast), in DRGs 269 and 270 (Other Skin, Subcutaneous
Tissue & Breast Procedure, with and without CC). Therefore, its
presence in any other MDC does not affect DRG assignment. Patients who
are admitted with renal failure and who have a VAD inserted will be
assigned to DRG 316 (Renal Failure), absent any other surgical
procedures. DRG 316 is a medical DRG with a lower relative weight than
cases in the surgical DRGs within the same MDC.
We extensively reviewed the MedPAR data. We found that code 86.07
appeared in 358 different DRGs. Of these 358 DRGs, 173 include
additional procedures recognized by GROUPER and are therefore
considered surgical, while 185 are medical. Because of the space
limitations of the ICD-9-CM, code 86.07 is used to describe VAD devices
used for other purposes than hemodialysis.
We looked specifically at the cases within DRGs 315 and 316 as
shown in the two tables below:
DRG 315 (Surgical)
------------------------------------------------------------------------
Without code
With code 86.07 86.07
------------------------------------------------------------------------
Number of Cases................. 421................ 19,815.
Average Length of Stay.......... 12.5 days.......... 6.8 days.
Average Charges................. $39,946............ $23,061.
------------------------------------------------------------------------
DRG 316 (Medical)
------------------------------------------------------------------------
Without code
With code 86.07 86.07
------------------------------------------------------------------------
Number of Cases................. 1,020.............. 19,815.
Average Length of Stay.......... 10.2 days.......... 6.6 days.
Average Charges................. $27,730............ $15,045.
------------------------------------------------------------------------
Cases containing code 86.07 have higher average lengths of stay as
well as higher average charges than cases not containing this code. We
further examined the total number of reported procedures, as well as
the range of average charges across both DRGs, for cases containing
code 86.07. Both DRGs contain a significant number of additional
procedures. The nature of these procedures varies widely, including
such divergent procedures as X-rays and scans, injections, dental
extraction, cardiac catheterization, aneurysm repair, and laparoscopic
cholecystectomy. We also identified 24 cases in DRG 315 and 28 cases in
DRG 316 with multiple insertions of the VAD. We believe those instances
where the VAD is inserted as an inpatient procedure involve cases where
other complications exist, leading to the higher average charges noted
above. We are not assigning code 86.07 to DRG 315 as a surgical
procedure, but will continue to consider possible alternative
specifications of these DRGs.
Additionally, we take this opportunity to clarify correct coding
practice. It has come to our attention that a brochure is being
distributed with the product that advocates coding insertion of the
Lifesite Hemodialysis Access System using ICD-9-CM procedure
code 86.07 in addition to code 39.93 (Insertion of vessel-to-vessel
cannula). Inclusion of code 39.93 will force these cases into DRG 315,
the higher weighted surgical DRG. Our data review showed 33 such cases
of double coding. We would caution hospitals that the use of code
39.93, in the absence of the actual procedure, is erroneous. According
to our vascular surgeon consultant, the LifeSite Hemodialysis
Access System as presented to us is not a vessel-to-vessel cannula. It
is a device inserted into a vessel. Therefore, providers submitting
code 39.93 without the actual procedure having been performed are at
risk for review of fraudulent coding practice and DRG upcoding.
This same product brochure contains the name and telephone number
of a nationally recognized coding specialist. The addition of this
specialist's name and number was included without her knowledge or
consent. We take this opportunity to reiterate that LifeSite
Hemodialysis Access System is correctly coded using 86.07 alone.
5. MDC 12 (Diseases and Disorders of the Male Reproductive System)
At its May 11, 2000 public meeting, the ICD-9-CM Coordination and
Maintenance Committee considered a request from a manufacturer to
create a unique code for the procedure Penile plethysmography with
nerve stimulation in DRG 334 (Major Male Pelvic Procedures with CC).
The penile plethysmography is a test that can be performed during a
radical prostatectomy procedure. During the course of the procedure,
the physician places a probe within an area where the prostatic nerves
are thought to be located and is able to detect minor changes in penile
tumescence or detumescence. This reaction tells the physician that the
nerve bundles have been located, which may aid the physician in
performing a nerve-sparing radical prostatectomy procedure with
precision. The nerve bundles can also be restimulated at the conclusion
of the procedure, providing immediate feedback as to whether erectile
function will be restored after surgery.
After a presentation on the nerve identifying procedure and review
of existing ICD-9-CM codes, the ICD-9-CM Coordination and Maintenance
Committee determined that the existing
[[Page 39846]]
code 89.58 (Plethysmogram) adequately describes this test.
Radical prostatectomies for patients with cancer of the prostate
are grouped in either DRG 334 (Major Male Pelvic Procedures with CC) or
DRG 335 (Major Male Pelvic Procedures without CC). We have received a
request from a manufacturer of a nerve-identifying device to assign
cases containing code 89.58 into DRG 334 only, not into DRG 335. DRG
334 results in higher payments to hospitals. For FY 2002, DRG 334 has a
relative weight of 1.5177, and DRG 335 has a relative weight of 1.1047.
The manufacturer requested that we designate code 89.58 as an operating
room procedure code that would be recognized by the GROUPER software,
and make that code applicable only to DRG 334. The manufacturer
believed that this would serve to take any cases of nerve sparing out
of the lower paying DRG 335, and would make the technology more
attractive to hospitals. As paired DRGs 334 and 335 are currently
structured, they differ only in whether or not a secondary diagnosis
identified as a CC is recorded.
We examined those cases in DRG 334 to which the procedure code for
prostatectomy was assigned. Of the total 7,241 cases in DRG 334
identified, 5,611 of these cases contained procedure code 60.5 (Radical
prostatectomy). Only three of the prostatectomy cases included code
89.58. There are not a sufficient number of cases on which to base an
assessment of the payment for this procedure. Therefore, we did not
propose to modify the assignment of code 89.58.
We received one comment on this proposal.
Comment: The commenter argued that the analysis conducted on the
procedure code assignment of 89.58 was incomplete, as it did not
include evaluation of DRG 335 in the calculations. The commenter added
that DRG also includes radical prostatectomies for patients with cancer
of the prostate.
Response: We apologize for the omission. Our review of data on DRG
335 showed that the DRG contained 8,125 total cases. There were 8,117
cases that did not contain procedure code 89.58; these cases had
average total charges of $12,808. There were 8 cases in this group
containing code 89.58. These 8 cases had average total charges of
$16,366. We found a subset of 7,050 cases containing procedure code
60.5; these cases had average total charges of $12,772. Within this
subset, only 7 cases were reported containing codes 60.5 and 89.58.
These 7 cases had average total charges of $16,593.
Even including these additional cases, we identified very few cases
in our analysis. Therefore, we are adopting as final our original
proposed decision not to modify the assignment of code 89.58 by
assigning it exclusively to DRG 334 within MDC 12. However, we will
continue to monitor this procedure to determine whether a change in DRG
assignment is warranted in the future.
6. MDC 15 (Newborns and Other Neonates With Conditions Originating in
the Perinatal Period)
DRG 390 (Neonate with Other Significant Problems) contains newborn
or neonate cases with other significant problems not assigned to DRGs
385 through 389, DRG 391, or DRG 469. To be assigned to DRG 389 (Full
Term Neonate with Major Problems), the neonate must have one of the
principal or secondary diagnosis listed under this DRG. A neonate is
assigned to DRG 390 when the neonate has a principal or secondary
diagnosis of newborn or neonate with other significant problems that
are not assigned to DRG 385 through 389, 391, or 469.
We have received correspondence suggesting a number of changes to
be made to DRGs 398 and 391. These changes involve removing two codes
from DRG 389 and adding 17 codes to DRG 391, as described below.
a. DRG 389 (Full Term Neonate with Major Problems)
The correspondent suggested removing the following codes from DRG
389 and assigning them to DRG 390:
773.0 Hemolytic disease due to RH isoimmunization
773.1 Hemolytic disease due to ABO isoimmunization
The correspondent stated that hemolytic disease due to RH
isoimmunization or due to ABO isoimmunization should not be considered
a major problem. The correspondent recommended that these two
conditions be classified as significant problems instead and thus
assigned to DRG 390.
Our medical consultants sought additional advice from the National
Association of Children's Hospitals and Related Institutions (NACHRI).
(CMS contracts with the 3M Health Information Systems to maintain the
DRG system. The medical experts at 3M evaluate proposed DRG changes
from a clinical perspective. These medical consultants assist CMS in
evaluating alternative proposals.) NACHRI and our medical consultants
agree that it is appropriate to remove codes 773.0 and 773.1 from DRG
389. Therefore, we proposed to remove 773.0 and 773.1 from DRG 389 so
that neonates with these conditions are assigned to DRG 390.
Comment: Several commenters supported the proposed revisions for
newborns within MDC 15. One commenter stated that the code assignments
mentioned in the proposed rule are more appropriately classified based
on their clinical attributes. Another commenter agreed with the
proposed changes, but requested that an additional code be added to
those being moved to DRG 391 (Normal Newborn). Specifically, the
commenter requested that code 779.3, Feeding problems in newborns, be
listed under DRG 391. Currently, when this code is listed as a
secondary code, it results in the assignment of the neonate to DRG 390.
The commenter stated that this condition and its resource consumption
should not cause the neonate to be classified under DRG 390.
Response: We discussed this additional issue with our medical
consultants and they agreed that code 779.3 should also be listed under
DRG 391. They concurred that the addition of this code as a secondary
diagnosis should not lead to the newborn being classified as having a
significant problem. Therefore, code 779.3 will be included among the
codes being moved to DRG 391 as of October 1, 2001.
Comment: One commenter suggested that codes 773.0 and 773.1 be
removed from DRG 387 (Prematurity with major problems) in addition to
DRG 389. The list of major problems in DRGs 389 and 387 mirror each
other. The only difference is that DRG 387 includes premature newborns.
The commenter asked us to consider codes 773.0 and 773.1 as significant
problems for newborns and classify them into DRG 390, which would make
them applicable for premature and full-term newborns.
Response: We agree with the commenter. We are removing codes 773.0
and 773.1 from DRG 389 as well as DRG 387. This removal will result in
these cases being assigned to DRG 390 (Neonate with Other Significant
Problems).
b. DRG 391 (Normal Newborn)
We also have received correspondence with recommendations for
changes to DRG 391. The correspondent pointed out that the following
secondary codes currently lead to the assignment of the neonate to DRG
390 (Neonate with Other Significant Problems). The correspondent
believed that the conditions described by these codes
[[Page 39847]]
should not cause the neonate to be classified under DRG 390 when
reported as a secondary diagnosis. The correspondent recommended that
these conditions be listed under DRG 391 (Normal Newborn).
478.1 Other diseases of nasal cavity and sinuses
520.6 Disturbances in tooth eruption
623.8 Other specified noninflammatory disorders of vagina
709.00 Dyschromia, unspecified
709.01 Vitiglio
709.09 Dyschromia, Other
744.1 Accessory auricle
754.61 Congenital pes planus
757.33 Congenital pigmentary anomalies of skin
757.39 Other specified anomaly of skin
764.08 ``Light for dates'' without mention of fetal malnutrition,
2,000-2,499 grams
764.98 Fetal growth retardation, unspecified, 2,000-2,499 grams
772.6 Cutaneous hemorrhage
794.15 Abnormal and auditory function studies
796.4 Other abnormal clinical findings
V20.2 Routine infant or child health check
V72.1 Examination of ears and hearing
Our medical consultants also sought the advice of NACHRI on this
recommendation. NACHRI reviewed the list of codes and agreed that none
of these conditions should be considered to be a significant problem
for a neonate. NACHRI concurred that neonates with these secondary
diagnoses should be classified as normal newborns. Therefore, we
proposed to add the codes listed above to DRG 391 and not classify them
to DRG 390 when reported as a secondary diagnosis.
Comment: One commenter expressed concern that the weights assigned
to five newborn DRGs (DRGs 385, 368, 387, 388, and 389) are
undervalued. The commenter pointed out that legislation mandating Early
Hearing Detection and Intervention (EHDI) has been passed in 35 States
plus the District of Columbia. In these States, hearing screening must
be performed prior to the newborn's discharge from the hospital unless
prevented by medical complications. The cost per screening ranges from
$15 to $30, which includes personnel, supplies, and equipment costs
which are amortized over 3 years. The screening also includes costs for
babies that require diagnostic evaluation.
The commenter requested that data from States that have not
implemented EHDI programs be deleted from the Medicare supplemental
database for, at a minimum, DRG 391 (Normal Newborn). The commenter
stated that non-Medicare data used for developing the weights for the
five newborn DRGs do not represent average costs if some of the 19
States that supply supplemental non-Medicare data are States that
perform hearing screenings on less than 90 percent of newborns. The
commenter further requested that we use data only from States that have
EHDI programs that are operational at the 90 percent level. The
commenter provided a list of States that meet these criteria.
Response: While we appreciate the commenter's furnishing us with
information on the costs of providing services such as hearing
screenings, it would be inappropriate for us to use this one service to
determine whether or not to include a State's data because the State
does not provide the service at a 90-percent level. The DRG weights are
based on averages. As hospitals elect to include or exclude services,
the weights will change over time. Therefore, we are not developing a
criterion to exclude hospital data from States that do not have a 90-
percent compliance level with EHDI.
Comment: One commenter noted that new procedure code 75.38, Fetal
pulse osimetry, was classified as a nonoperative procedure code in
Table 6B of the Addendum of the proposed rule. As a nonoperative
procedure, it was not assigned to an MDC or to specific DRGs. The
commenter requested that we assign code 75.38 to MDC 14 (Pregnancy,
Childbirth and Puerperium), and the following DRGs:
DRG 370--(Caesarean Section with CC)
DRG 371--(Caesarean Section without CC)
DRG 372--(Vaginal Delivery with Complicating Diagnosis)
DRG 373--(Vaginal Delivery without CC)
The commenter believed it was critical that the clinical benefits
and use of fetal pulse oximetry be closely tracked in order to monitor
clinical outcomes and to recognize potential economic advantages. The
commenter acknowledged that most labor and delivery patients are not
Medicare beneficiaries. However, other third party payers benchmark
hospital inpatient payment rates from Medicare DRGs. The commenter
stated that if code 75.38 does not contribute or link to a DRG, it is
often simply not coded. The commenter further stated that fetal
oximetry is an exciting and significant emerging technology and that
much knowledge can be gained by understanding its usage in the context
of labor and delivery services.
Response: The commenter requested that 75.38 be assigned to the
DRGs for deliveries (DRG 370 through 373). However, these DRGs are
currently assigned based on the procedure codes for the specific type
of delivery (caesarian or vaginal). Adding the procedure code 75.38 to
these delivery DRGs would not affect the DRG assignment. The cases
would still be assigned to the appropriate DRG based on the type of
delivery, not whether the baby received fetal pulse oximetry. If the
commenter is suggesting that the fetal pulse oximetry code, on its own,
should lead to the DRG assignment, this option is not workable. Without
knowing that the mother actually delivered, and the type of delivery,
one would not be able to assign the case to one of the delivery DRGs.
Once one knew through the procedure codes that the mother delivered,
and the type of delivery, the addition of 75.38 would not add to the
DRG assignment.
The commenter did not make an argument as to why 75.38 was
incorrectly classified as a nonoperating room procedure. While we
appreciate the commenter's desire that this new procedure code be used,
assigning the code to existing DRGs is not consistent with the
structure of DRGs. Procedure codes are only assigned to DRGs when they
effect the DRG assignment logic. Therefore, we are not changing the
operating room status of code 75.38, nor are we adding it to the
delivery DRGs. Code 75.38 will be considered a nonoperative procedure.
c. Medicare Code Editor Changes
The Medicare Code Editor (MCE) is a front-end software program that
detects and reports errors in the coding of claims data. The age
conflict edit detects inconsistencies between a patient's age and any
diagnosis on the patient's record. A subset of diagnoses is considered
valid only for patients over the age of 14 years. These diagnoses are
identified as ``adult'' diagnoses and range in age from 15 through 124
years. Therefore, any codes included on the Newborn Diagnoses edit are
valid only for patients under age 14.
It has come to our attention that cases including the ICD-9-CM code
770.7, Chronic respiratory disease arising in the perinatal period, are
being rejected. However, a condition such as bronchopulmonary dysplasia
always originates in the perinatal period, so regardless of the
patient's age, this condition is always coded as 770.7. The age at
which the diagnosis was established or the age at continuing treatment
does not affect the assignment of code 770.7.
[[Page 39848]]
Because correct coding is causing these claims to be rejected, in
the May 4 proposed rule we proposed to remove code 770.7 from the
Newborn Diagnoses edit in the MCE, as well as remove it from DRG 387
(Prematurity with Major Problems) and DRG 389 (Full Term Neonate with
Major Problems). Clinical conditions in code 770.7, such as pulmonary
fibrosis, would group to DRG 92 (Interstitial Lung Disease with CC) and
DRG 93 (Interstitial Lung Disease without CC). Therefore, we proposed
the addition of code 770.7 to DRGs 92 and 93, as they are most similar
clinically. We indicated that we would monitor these cases in upcoming
MedPAR data to ascertain that the cases consume similar resources.
We received no comments on these proposals, and are, therefore,
adopting the change as final.
7. MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental
Disorders)
DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other
Symptomatic Treatment with CC) is assigned when the patient has a
principal diagnosis of alcohol or drug abuse or dependence along with a
secondary diagnosis classified as a CC. If these patients do not have a
CC, they are assigned to DRG 435 (Alcohol/Drug Abuse or Dependency,
detoxification or Other Symptomatic Treatment without CC). When the
patients receive rehabilitation and detoxification therapy during the
stay, they are assigned to DRG 437 (Alcohol/Drug Dependence, Combined
Rehabilitation and Detoxification Therapy). If the patients receive
only rehabilitation therapy, they are assigned to DRG 436 (Alcohol/Drug
Dependence with Rehabilitation Therapy).
We have received inquiries as to why the relative weight for DRG
437, which includes both rehabilitation and detoxification (for FY
2001, the relative weight is .6606, with a geometric mean length of
stay of 7.5) is lower than the FY 2001 relative weight for DRG 434,
which includes only detoxification (.7256, with a geometric mean length
of stay of 3.9). Likewise, the FY 2001 relative weight for DRG 436,
which includes only rehabilitation (.7433), is higher than the FY 2001
relative weight for DRG 437, which includes combined rehabilitation and
detoxification therapy (.6606). The inquirers indicated that those
patients receiving the combination therapy would be expected to have a
longer length of stay, require more services, and, therefore, be more
costly to treat.
We analyzed data from the FY 2000 MedPAR file and did not find
support for the inquirers' assertion that combination therapy is more
costly to treat. The relative weights indicate that the presence of a
CC in DRG 434 leads to a significantly higher weight than is found in
DRG 435, which does not have a CC. Therefore, we analyzed the alcohol/
drug DRGs and focused on eliminating the distinction between
rehabilitation and rehabilitation with detoxification and assessing the
impact of CCs. We combined data on DRGs 436 and 437 and then subdivided
the data based on the presence or absence of a CC. The following table
contains the results of the analysis.
Average Charges for Cases--With and Without CCs
----------------------------------------------------------------------------------------------------------------
With CC Without CC
-----------------------------------------------------------------
DRGS Length of Length of
Count Charge stay Count Charge stay
----------------------------------------------------------------------------------------------------------------
Detoxification Cases--DRG 434 and DRG 435..... 3,298 $8,548 5.0 9,689 $5,111 4.1
All Rehabilitation Cases--DRG 436 and DRG 437. 3,298 8,117 10.1 4,473 7,407 9.6
----------------------------------------------------------------------------------------------------------------
We found that, for both the detoxification and rehabilitation DRGs,
the with-CC group has higher charges than the without-CC group.
However, the with-CC groups still contain the anomaly that the
detoxification DRG 434 has a slightly higher average charge than the
combined rehabilitation DRGs 436 and 437. It appears that any
significant medical problems as indicated by the presence of a CC
dominate the cost incurred by hospitals for treating alcohol and drug
abuse patients. For the without-CC groups, the detoxification DRG 435
has substantially lower average charges than the combined
rehabilitation DRGs 436 and 437. Because the average charges of the
with-CC for both the detoxification DRG 434 and combined rehabilitation
DRGs 436 and 437 have similar average charges, we proposed to combine
these two groups.
Based on the results of our analysis, we proposed to restructure
MDC 20 as follows. We first identified those cases with a principal
diagnosis within MDC 20 where the patient left against medical advice.
These cases are found in DRG 433 (Alcohol/Drug Abuse or Dependence,
Left Against Medical Advice (AMA)). We next identified all remaining
cases with a principal diagnosis within MDC 20 where there was a CC. We
assigned these cases to a new DRG, (Alcohol/Drug Abuse or Dependence
with CC). The remaining cases (without CC and did not leave against
medical advice) were then divided into two new DRGs based on whether or
not the patient received rehabilitation (Alcohol/Drug Abuse or
Dependence without CC, with Rehabilitation Therapy; and Alcohol/Drug
Abuse or Dependence without CC, without Rehabilitation Therapy).
The following table illustrates the number of patients and average
charges for each of the four proposed DRGs.
Frequencies and Average Charges for New DRGs
------------------------------------------------------------------------
Number of Average
DRG Group title cases charges
------------------------------------------------------------------------
433................. Alcohol/Drug Abuse or 3,509 $3,855
Dependence, Left
Against Medical Advice.
521................. Alcohol/Drug Abuse or 18,235 8,470
Dependence with CC.
522................. Alcohol/Drug Abuse or 4,473 7,407
Dependence without CC,
with Rehabilitation
Therapy.
523................. Alcohol/Drug Abuse or 9,689 5,111
Dependence without CC,
without Rehabilitation
Therapy.
------------------------------------------------------------------------
[[Page 39849]]
This table illustrates that groups based first on the presence of
CC and then on whether or not the patient receives rehabilitation
therapy provide a much better explanation of differences in charges.
Therefore, we proposed to retain DRG 433, make DRGs 434 through 437
invalid, and create new DRGs 521, 522, and 523 to include the diagnosis
and procedure codes reflected in Chart 7 below.
Chart 7.--Restructure of MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders)
----------------------------------------------------------------------------------------------------------------
Included in
Diagnosis and procedure code Existing DRG Included in DRG Included in DRG Included in DRG
433 521 522 523
----------------------------------------------------------------------------------------------------------------
Principal diagnosis:
All principal diagnosis within existing X ............... ............... ...............
MDC 20 involving cases in which
patients left against medical advice
(AMA)..................................
All principal diagnoses within existing ............... X ............... ...............
MDC 20 where there is a CC and where
patient did not leave against medical
advice (AMA)...........................
All principal diagnoses within existing
MDC 20 without CC and where patient did
not leave against medical advice (AMA).
All principal diagnoses in existing MDC ............... ............... ............... X
20 without CC involving cases where
patients did not leave against medical
advice (AMA)...........................
Procedure Codes:
94.61 Alcohol rehabilitation........... ............... ............... X ...............
94.63 Alcohol rehabilitation and ............... ............... X ...............
detoxification.........................
94.64 Drug rehabilitation.............. ............... ............... X ...............
94.66 Drug rehabilitation and ............... ............... X ...............
detoxification.........................
94.67 Combined alcohol and drug ............... ............... X ...............
rehabilitation.........................
94.69 Combined alcohol and drug ............... ............... X ...............
rehabilitation and detoxification......
----------------------------------------------------------------------------------------------------------------
Comment: One commenter was uncertain as to the intent of the
reclassification of the DRGs to identify alcohol/drug use and alcohol/
drug-induced organic mental disorders. The commenter expressed concern
that the cases associated with alcohol/drug use would have a lower
overall weight relative to the overall average weight of these cases in
FY 2001. The commenter requested further information on the impact of
this change in the final rule. Additionally, the commenter recommended
that the title for DRG 521 be changed from ``Alcohol/Drug Abuse or
Dependence with CC'' to ``Alcohol/Drug Abuse with CC, with or without
Rehabilitation Therapy.''
Response: As described above, for FY 2001, cases receiving combined
rehabilitation and detoxification (DRG 437) had a lower relative weight
than patients receiving only detoxification (DRG 434) or rehabilitation
(DRG 436). Since these relative weights are derived from actual claims
data, we decided to review the issue to determine if other factors had
any impact. It would be expected that those patients receiving the
combination therapy would have a longer length of stay, require more
services, and therefore be more costly to treat. This was not supported
by the data.
The factor that seems to contribute the greatest to the costs of
these cases is the presence of a CC. The presence of a CC had a greater
impact on the average charges than did factors such as detoxification
or rehabilitation. Once the importance of this factor was determined,
the cases not leaving against medical advice (DRG 433) were split on
whether or not a CC was present. Those with a CC were assigned to new
DRG 521. The remaining cases were then split based on whether or not
rehabilitation was provided.
As can be seen from the FY 2002 relative weights in the chart
below, MDC 20 patients who have a CC are considerably more expensive to
treat. They have the highest relative weight among this set of DRGs.
The second highest weight is assigned to MDC 20 cases without CC who
also received rehabilitation services.
------------------------------------------------------------------------
Number of Final
DRG title of cases weights
------------------------------------------------------------------------
DRG 433 Alcohol/Drug Abuse or Dependence, Left 5,522 .2888
AMA..........................................
DRG 521 Alcohol/Drug Abuse or Dependence with 28,014 .7355
CC...........................................
DRG 522 Alcohol/Drug Abuse or Dependence 6,852 .6249
without CC, with Rehabilitation Therapy......
DRG 523 Alcohol/Drug Abuse or Dependence 14,954 .3997
without CC, without Rehabilitation Therapy...
------------------------------------------------------------------------
As can be seen from this chart, the majority of patients are
assigned to DRG 521, which has the highest relative weight among the
MDC 20 DRGs. As is the case for all DRGs, the relative weights reflect
hospitals' actual charges submitted for bills in the FY 2000 MedPAR
file. Data support the new splits based first on the presence of a CC
and then on the presence of rehabilitation therapy. Therefore, we are
adopting the proposed DRG classification changes as final without
change.
While we appreciate the comment on modifying the title for DRG 521,
we believe that it does not add to the clarity of the DRG. All MDC 20
patients who have not left AMA but who have a CC are assigned to DRG
521. The presence or absence of a code for rehabilitation therapy does
not effect the DRG assignment for these cases. Therefore, we are
adopting the proposed title as final without change.
8. MDC 25 (Human Immunodeficiency Virus Infections)
Effective October 1, 2000, ICD-9-CM diagnosis codes 783.2 (Abnormal
loss of weight) and 783.4 (Lack of expected normal physiological
development) were made invalid (65 FR 47171). These
[[Page 39850]]
two old diagnosis codes were expanded to five digits and the following
new diagnosis codes were created:
783.21 Loss of weight
783.22 Underweight
783.40 Unspecified lack of normal physiological development
783.41 Failure to thrive
783.42 Delayed milestones
783.43 Short stature
These six revised codes were created in response to an industry
request. Specifically, code 783.2 did not differentiate between whether
the patient had lost weight recently or whether the patient was
underweight. Code 783.4 was expanded to capture concepts such as
failure to thrive, delayed milestones, and short stature. None of these
concepts were captured in the old codes.
We listed these new codes in the August 1, 2000 final rule on the
hospital inpatient prospective payment system in Table 6A--New
Diagnosis Codes (65 FR 47169). At the time the final rule was
published, all of these codes were assigned to DRGs 296 through 298.
After the final rule was published, we received an inquiry as to why
these new diagnosis codes were not included in MDC 25 as human
immunodeficiency virus (HIV)-related conditions. The inquirer pointed
out that the predecessor codes (783.2 and 783.4) were included in MDC
25 as HIV-related conditions and suggested that the new codes be added
to MDC 25. These cases will be assigned to other MDCs if the patient
does not have HIV.
In the proposed rule, we stated that we agreed that the expanded
codes should have been placed in the MDC 25 as HIV-related conditions.
The omission was an oversight. Therefore, we proposed to add diagnosis
codes 783.21, 783.22, 783.40, 783.41, 783.42, and 783.43 as HIV-related
conditions within MDC 25. When these six revised codes are reported
with code 042 HIV, the patient will be classified within MDC 25.
Comment: One commenter supported the placement of codes 783.21,
783.22, 783.40, 783.41, 783.42, and 783.43, as HIV-related conditions
within MDC 25.
Response: We appreciate the commenter's support and are adopting
the proposed changes as final.
9. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in assignment of the case
to a different DRG within the MDC to which the principal diagnosis is
assigned. Therefore, it is 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 resource intensive to least,
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 11, the surgical class ``kidney transplant'' consists of a
single DRG (DRG 302) and the class ``kidney, ureter and major bladder
procedures'' consists of three DRGs (DRGs 303, 304, and 305).
Consequently, in many cases, the surgical hierarchy has an impact on
more than one DRG. The methodology for determining the most resource-
intensive surgical class involves weighting each DRG for frequency to
determine the average resources for each surgical class. For example,
assume surgical class A includes DRGs 1 and 2 and surgical class B
includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1
is higher than that of DRG 3, but the average charges of DRGs 4 and 5
are higher than the average charge of DRG 2. To determine whether
surgical class A should be higher or lower than surgical class B in the
surgical hierarchy, we would weight the average charge of each DRG by
frequency (that is, by the number of cases in the DRG) to determine
average resource consumption for the surgical class. The surgical
classes would then be ordered from the class with the highest average
resource utilization to that with the lowest, with the exception of
``other OR procedures'' as discussed below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average relative
weight is ordered above a surgical class with a higher average relative
weight. For example, the ``other OR procedures'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weight for the DRG
or DRGs in that surgical class may be higher than that for other
surgical classes in the MDC. The ``other OR procedures'' class is a
group of procedures that are least likely to be related to the
diagnoses in the MDC but are occasionally performed on patients with
these diagnoses. Therefore, these procedures should only be considered
if 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 the
modification of the surgical hierarchy as set forth below. As we stated
in the September 1, 1989 final rule (54 FR 36457), we are unable to
test the effects of proposed revisions to the surgical hierarchy and to
reflect these changes in the proposed relative weights due to the
unavailability of the revised GROUPER software at the time the proposed
rule is prepared. Rather, we simulate most major classification changes
to approximate the placement of cases under the proposed
reclassification and then determine the average charge for each DRG.
These average charges then serve as our best estimate of relative
resource use for each surgical class. We test the proposed surgical
hierarchy changes after the revised GROUPER is received and reflect the
final changes in the DRG relative weights in the final rule. Further,
as discussed in section II.C. of this preamble, we anticipate that the
final recalibrated weights will be somewhat different from those
proposed, because they will be based on more complete data.
Consequently, in the proposed rule we stated that further revision of
the hierarchy, using the above principles, might be necessary in the
final rule.
In the May 4 proposed rule, we proposed to revise the surgical
hierarchy for the pre-MDC DRGs, MDC 5 (Diseases and Disorders of the
Circulatory System), MDC 8 (Diseases
[[Page 39851]]
and Disorders of the Musculoskeletal System & Connective Tissue) and
MDC 20 (Alcohol/Drug Use & Alcohol/Drug Induced-Organic Mental
Disorders) as follows:
In the pre-MDC DRGs, we proposed to reorder Lung
Transplant (DRG 495) above Bone Marrow Transplant (DRG 481). We also
proposed to reorder Simultaneous Pancreas/Kidney Transplant (DRG 512)
and Pancreas Transplant (DRG 513) above Lung Transplant (DRG 495).
In MDC 5, we proposed to reorder Cardiac Defibrillator
Implants (DRGs 514 and 515) above Other Cardiothoracic Procedures (DRG
108). We also proposed to reorder Percutaneous Cardiovascular
Procedures (DRGs 516, 517, and 518) above Other Vascular Procedures
(DRGs 478 and 479).
In MDC 8, we proposed to reorder Cervical Spinal Fusion
(DRGs 519 and 520) above Back & Neck Procedures Except Spinal Fusion
(DRGs 499 and 500).
In MDC 20, we proposed to order as follows: Alcohol/Drug
Abuse or Dependence, Left AMA (DRG 433) above Alcohol/Drug Abuse or
Dependence With CC (DRG 521); Alcohol/Drug Abuse or Dependence With CC
(DRG 521) above Alcohol/Drug Abuse or Dependence With Rehabilitation
Therapy Without CC (DRG 522); and Alcohol/Drug Abuse or Dependence With
Rehabilitation Therapy Without CC (DRG 522) above Alcohol/Drug Abuse or
Dependence Without Rehabilitation Therapy Without CC (DRG 523).
Comment: One commenter expressed support for hierarchy proposals.
Response: We appreciate the commenter's support. Based on a test of
the proposed revisions using the March 2001 update of the FY 2000
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 adopting these proposed changes as
final.
10. Refinement of Complications and Comorbidities (CC) List
In the September 1, 1987 final notice (52 FR 33143) concerning
changes to the DRG classification system, 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 for the following reasons: (1) to preclude coding of CCs for
closely related conditions; (2) to preclude duplicative coding or
inconsistent coding from being treated as CCs; and (3) to ensure that
cases are appropriately classified between the complicated and
uncomplicated DRGs in a pair. We developed this standard list of
diagnoses using physician panels to include those diagnoses that, when
present as a secondary condition, would be considered a substantial
complication or comorbidity. In previous years, we have made changes to
the standard list of CCs, either by adding new CCs or deleting CCs
already on the list. We stated in the proposed rule that we did not
propose to delete any of the diagnosis codes on the CC list at that
time.
In the May 19, 1987 proposed notice (52 FR 18877) concerning
changes to the DRG classification system, 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 coexist, such as partial/total,
unilateral/bilateral, obstructed/unobstructed, and benign/malignant,
should not be considered CCs for one another.
The same condition in anatomically proximal sites should
not be considered CCs for one another.
Closely related conditions should not be considered CCs
for one another.
The creation of the CC Exclusions List was a major project
involving hundreds of codes. The FY 1988 revisions were intended only
as 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 (53 FR 38485) for the revision made for the discharges
occurring in FY 1989; the September 1, 1989 final rule (54 FR 36552)
for the FY 1990 revision; the September 4, 1990 final rule (55 FR
36126) for the FY 1991 revision; the August 30, 1991 final rule (56 FR
43209) for the FY 1992 revision; the September 1, 1992 final rule (57
FR 39753) for the FY 1993 revision; the September 1, 1993 final rule
(58 FR 46278) for the FY 1994 revisions; the September 1, 1994 final
rule (59 FR 45334) for the FY 1995 revisions; the September 1, 1995
final rule (60 FR 45782) for the FY 1996 revisions; the August 30, 1996
final rule (61 FR 46171) for the FY 1997 revisions; the August 29, 1997
final rule (62 FR 45966) for the FY 1998 revisions; the July 31, 1998
final rule (63 FR 40954) for the FY 1999 revisions, and the August 1,
2000 final rule (65 FR 47064) for the FY 2001 revisions.) In the July
30, 1999 final rule (64 FR 41490) we did not modify the CC Exclusions
List for FY 2000 because we did not make any changes to the ICD-9-CM
codes for FY 2000.
In this final rule, we are making a limited revision of the CC
Exclusions List to take into account the changes that will be made in
the ICD-9-CM diagnosis coding system effective October 1, 2001. (See
section II.B.11. below, for a discussion of ICD-9-CM changes.) These
changes are being made in accordance with the principles established
when we created the CC Exclusions List in 1987.
Tables 6F and 6G in section V. of the Addendum to this final rule
contain the revisions to the CC Exclusions List that will be effective
for discharges occurring on or after October 1, 2001. Each table shows
the principal diagnoses with changes to the excluded CCs. Each of these
principal diagnoses is shown with an asterisk, and the additions or
deletions to the CC Exclusions List are provided in an indented column
immediately following the affected principal diagnosis.
CCs that are added to the list are in Table 6G--Additions to the CC
Exclusions List. Beginning with discharges on or after October 1, 2001,
the indented diagnoses will not be recognized by the GROUPER as valid
CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6H--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 2001, the indented diagnoses will be recognized by the GROUPER as
valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can
be obtained from the National Technical Information Service (NTIS) of
the Department of Commerce. It is available in hard copy for $133.00
plus shipping and handling. A request for the FY 1988 CC Exclusions
List (which should
[[Page 39852]]
include the identification accession number (PB) 88-133970) should be
made to the following address: National Technical Information Service,
United States Department of Commerce, 5285 Port Royal Road,
Springfield, VA 22161; or by calling (800) 553-6847.
Users should be aware of the fact that all revisions to the CC
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996,
1997, 1998, and 1999) and those in Tables 6F and 6G of this document
must be incorporated into the list purchased from NTIS in order to
obtain the CC Exclusions List applicable for discharges occurring on or
after October 1, 2001. (Note: There was no CC Exclusions List in FY
2000 because we did not make changes to the ICD-9-CM codes for FY
2000.)
Alternatively, the complete documentation of the GROUPER logic,
including the current CC Exclusions List, is available from 3M/Health
Information Systems (HIS), which, under contract with CMS, is
responsible for updating and maintaining the GROUPER program. The
current DRG Definitions Manual, Version 18.0, is available for $225.00,
which includes $15.00 for shipping and handling. Version 19.0 of this
manual, which includes the final FY 2002 DRG changes, will be available
in October 2001 for $225.00. These manuals may be obtained by writing
3M/HIS at the following address: 100 Barnes Road, Wallingford, CT
06492; or by calling (203) 949-0303. Please specify the revision or
revisions requested.
11. 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) 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 are related to the principal diagnosis.
These DRGs are intended to capture atypical cases, that is, those cases
not occurring with sufficient frequency to represent a distinct,
recognizable clinical group. DRG 476 is assigned to those discharges in
which one or more of the following prostatic procedures are performed
and are unrelated to the principal diagnosis:
60.0 Incision of prostate
60.12 Open biopsy of prostate
60.15 Biopsy of periprostatic tissue
60.18 Other diagnostic procedures on prostate and periprostatic tissue
60.21 Transurethral prostatectomy
60.29 Other transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostatic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with
DRG 477 assigned to those discharges in which the only procedures
performed are nonextensive procedures that are unrelated to the
principal diagnosis. The original list of the ICD-9-CM procedure codes
for the procedures we consider nonextensive procedures, if performed
with an unrelated principal diagnosis, was published in Table 6C in
section IV. of the Addendum to the September 30, 1988 final rule (53 FR
38591). As part of the final rules published on September 4, 1990 (55
FR 36135), August 30, 1991 (56 FR 43212), September 1, 1992 (57 FR
23625), September 1, 1993 (58 FR 46279), September 1, 1994 (59 FR
45336), September 1, 1995 (60 FR 45783), August 30, 1996 (61 FR 46173),
and August 29, 1997 (62 FR 45981), we moved several other procedures
from DRG 468 to 477, and some procedures from DRG 477 to 468. No
procedures were moved in FY 1999, as noted in the July 31, 1998 final
rule (63 FR 40962); in FY 2000, as noted in the July 30, 1999 final
rule (64 FR 41496); or in FY 2001, as noted in the August 1, 2000 final
rule (65 FR 47064).
a. Moving Procedure Codes From DRGs 468 or 477 to MDCs
We annually conduct a review of procedures producing assignment to
DRG 468 or DRG 477 on the basis of volume, by procedure, to see if it
would be appropriate to move procedure codes out of these DRGs into one
of the surgical DRGs for the MDC into which the principal diagnosis
falls. The data are arrayed two ways for comparison purposes. We look
at a frequency count of each major operative procedure code. We also
compare procedures across MDCs by volume of procedure codes within each
MDC.
Our medical consultants identified those procedures occurring in
conjunction with certain principal diagnoses with sufficient frequency
to justify adding them to one of the surgical DRGs for the MDC in which
the diagnosis falls. Based on this year's review, we did not identify
any necessary changes in procedures under DRG 477 and, therefore, we
did not propose to move any procedures from DRG 477 to one of the
surgical DRGs. However, our medical consultants have identified a
number of procedure codes that should be removed from DRG 468 and put
into more clinically coherent DRGs. The movements of these codes are
specified in the charts below:
Movement of Procedure Codes From DRG 468
----------------------------------------------------------------------------------------------------------------
Included in
Procedure code Description DRG Description
----------------------------------------------------------------------------------------------------------------
MDC 1--Diseases and Disorders of the Nervous System
----------------------------------------------------------------------------------------------------------------
5495........................ Peritoneal Incision............. 7 Peripheral and Cranial Nerve and
Other Nervous System Procedures
with CC.
5495........................ Peritoneal Incision............. 8 Peripheral and Cranial Nerve and
Other Nervous System Procedures
without CC.
----------------------------------------------------------------------------------------------------------------
MDC 3--Diseases and Disorders of the Ear
----------------------------------------------------------------------------------------------------------------
3821........................ Blood Vessel Biopsy............. 63 Other Ear, Nose, Mouth and
Throat OR Procedure.
----------------------------------------------------------------------------------------------------------------
MDC 4--Diseases and Disorders of the Respiratory System
----------------------------------------------------------------------------------------------------------------
3821........................ Blood Vessel Biopsy............. 76 Other Respiratory System OR
Procedures with CC.
[[Page 39853]]
3821........................ Blood Vessel Biopsy............. 77 Other Respiratory System OR
Procedures with CC.
3929........................ Vascular Shunt & Bypass NEC..... 76 Other Respiratory System OR
Procedures with CC.
3929........................ Vascular Shunt & Bypass NEC..... 77 Other Respiratory System OR
Procedures with CC.
3931........................ Suture of Artery................ 76 Other Respiratory System OR
Procedures with CC.
3931........................ Suture of Artery................ 77 Other Respiratory System OR
Procedures with CC.
5411........................ Exploratory Laparotomy.......... 76 Other Respiratory System OR
Procedures with CC.
5411........................ Exploratory Laparotomy.......... 77 Other Respiratory System OR
Procedures with CC.
7749........................ Bone Biopsy NEC................. 76 Other Respiratory System OR
Procedures with CC.
7749........................ Bone Biopsy NEC................. 77 Other Respiratory System OR
Procedures with CC.
8669........................ Free Skin Graft NEC............. 76 Other Respiratory System OR
Procedures with CC.
8669........................ Free Skin Graft NEC............. 77 Other Respiratory System OR
Procedures with CC.
----------------------------------------------------------------------------------------------------------------
MDC 5--Diseases and Disorders of the Circulatory System
----------------------------------------------------------------------------------------------------------------
3402........................ Exploratory Thoracotomy......... 120 Other Circulatory System OR
Procedures.
3403........................ Reopen Thoractomy Site.......... 120 Other Circulatory System OR
Procedures.
3421........................ Transpleura Thoracoscopy........ 120 Other Circulatory System OR
Procedures.
3422........................ Mediastinoscopy................. 120 Other Circulatory System OR
Procedures.
3426........................ Open Mediastinal Biopsy......... 120 Other Circulatory System OR
Procedures.
436......................... Distal Gastrectomy.............. 120 Other Circulatory System OR
Procedures.
437......................... Partial Gastrectomy with Jejunal 120 Other Circulatory System OR
Anastomosis. Procedures.
4389........................ Partial Gastrectomy............. 120 Other Circulatory System OR
Procedures.
4399........................ Total Gastrectomy............... 120 Other Circulatory System OR
Procedures.
4561........................ Multiple Segment Small Bowel 120 Other Circulatory System OR
Excision. Procedures.
4562........................ Partial Small Bowel Resection 120 Other Circulatory System OR
NEC. Procedures.
4572........................ Cecectomy....................... 120 Other Circulatory System OR
Procedures.
4573........................ Right Hemicolectomy............. 120 Other Circulatory System OR
Procedures.
4574........................ Transverse Colon Resection...... 120 Other Circulatory System OR
Procedures.
4575........................ Left Hemicolectomy.............. 120 Other Circulatory System OR
Procedures.
4579........................ Partial Large Bowel Excision NEC 120 Other Circulatory System OR
Procedures.
458......................... Total Intra-Abdominal Colectomy. 120 Other Circulatory System OR
Procedures.
4593........................ Small-to-Large Bowel NEC........ 120 Other Circulatory System OR
Procedures.
4603........................ Large Bowel Exteriorization..... 120 Other Circulatory System OR
Procedures.
4613........................ Permanent Colostomy............. 120 Other Circulatory System OR
Procedures.
4709........................ Other Appendectomy.............. 120 Other Circulatory System OR
Procedures.
4862........................ Anterior Rectal Resection With 120 Other Circulatory System OR
Colostomy. Procedures.
4863........................ Anterior Rectal Resection NEC... 120 Other Circulatory System OR
Procedures.
4869........................ Rectal Resection................ 120 Other Circulatory System OR
Procedures.
5012........................ Open Liver Biopsy............... 120 Other Circulatory System OR
Procedures.
540......................... Abdominal Wall Incision......... 120 Other Circulatory System OR
Procedures.
----------------------------------------------------------------------------------------------------------------
MDC 6--Diseases and Disorders of the Digestive System
----------------------------------------------------------------------------------------------------------------
5122........................ Cholecystectomy................. 170 Other Digestive System OR
Procedures with CC.
5122........................ Cholecystectomy................. 171 Other Digestive System OR
Procedures without CC.
5123........................ Laparoscopic Cholecystectomy.... 170 Other Digestive System OR
Procedures with CC.
5132........................ GB-To-Intestine Anastomosis..... 170 Other Digestive System OR
Procedures with CC.
5136........................ Choledochoenterostomy........... 170 Other Digestive System OR
Procedures with CC.
5136........................ Choledochoenterostomy........... 171 Other Digestive System OR
Procedures without CC.
5137........................ Hepatic Duct-GI Anastomosis..... 170 Other Digestive System OR
Procedures with CC.
5137........................ Hepatic Duct-GI Anastomosis..... 171 Other Digestive System OR
Procedures without CC.
5159........................ Bile Duct Incision NEC.......... 170 Other Digestive System OR
Procedures with CC.
5159........................ Bile Duct Incision NEC.......... 171 Other Digestive System OR
Procedures without CC.
----------------------------------------------------------------------------------------------------------------
MDC 7--Diseases and Disorders of the Hepatobiliary System and Pancreas
----------------------------------------------------------------------------------------------------------------
540......................... Abdominal Wall Incision......... 201 Other Heptobiliary and Pancreas
Procedure.
----------------------------------------------------------------------------------------------------------------
MDC 8--Diseases and Disorders of the Musculoskeletal System and Connective Tissue
----------------------------------------------------------------------------------------------------------------
3479........................ Other Chest Wall Repair......... 233 Other Musculoskeletal System &
Connective Tissue OR Procedure
with CC.
3479........................ Other Chest Wall Repair......... 234 Other Musculoskeletal System &
Connective Tissue OR Procedure
with CC.
----------------------------------------------------------------------------------------------------------------
MDC 11--Diseases and Disorders of the Kideny and Urinary Tract
----------------------------------------------------------------------------------------------------------------
540......................... Abdominal Wall Incision......... 315 Other Kidney & Urinary Tract OR
Procedure.
5451........................ Laparoscopic Periton 315 Other Kidney & Urinary Tract OR
Adhesiolysis. Procedure.
5459........................ Other Periton Adhesiolysis...... 315 Other Kidney & Urinary Tract OR
Procedure.
----------------------------------------------------------------------------------------------------------------
[[Page 39854]]
b. Reassignment of Procedures among DRGs 468, 476, and 477
We also annually review the list of ICD-9-CM procedures that, when
in combination with their principal diagnosis code, result in
assignment to DRGs 468, 476, and 477, to ascertain if any of those
procedures should be moved from one of these DRGs to another of these
DRGs based on average charges and length of stay. We look at the data
for trends such as shifts in treatment practice or reporting practice
that would make the resulting DRG assignment illogical. If our medical
consultants were to find these shifts, we would propose moving cases to
keep the DRGs clinically similar or to provide payment for the cases in
a similar manner. 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.
c. Adding Diagnosis Codes to MDCs
Based on our review this year, we did not propose to add any
diagnosis codes to MDCs.
We received one comment in support of the proposed changes to the
procedure codes in DRG 468, 476, and 477. In this final rule, we are
adopting these proposed changes without further modification.
12. 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 CMS, charged with maintaining and updating
the ICD-9-CM system. The Committee is jointly responsible for 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
CMS 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
implementation in FY 2002 at public meetings held on May 11, 2000 and
November 17, 2000, and finalized the coding changes after consideration
of comments received at the meetings and in writing by January 08,
2001.
Copies of the Coordination and Maintenance Committee minutes of the
2000 meetings can be obtained from the CMS home page at: http://www.hcfa.gov/medicare/icd9cm.htm. 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, MD 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; CMS, Center for Medicare Management,
Purchasing Policy Group, Division of Acute Care; C4-07-07; 7500
Security Boulevard; Baltimore, MD 21244-1850. Comments may be sent by
E-mail to: [email protected].
The ICD-9-CM code changes that have been approved will become
effective October 1, 2001. The new ICD-9-CM codes are listed, along
with their DRG classifications, in Tables 6A and 6B (New Diagnosis
Codes and New Procedure Codes, respectively) in section V. of the
Addendum to this final rule. As we stated above, the code numbers and
their titles were presented for public comment at the ICD-9-CM
Coordination and Maintenance Committee meetings. Both oral and written
comments were considered before the codes were approved. In the
proposed rule, we solicited comments only on the proposed DRG
classification of these new codes.
Further, the Committee has approved the expansion of certain ICD-9-
CM codes to require an additional digit for valid code assignment.
Diagnosis codes that have been replaced by expanded codes or other
codes or have been deleted are in Table 6C (Invalid Diagnosis Codes).
These invalid diagnosis codes will not be recognized by the GROUPER
beginning with discharges occurring on or after October 1, 2001. For
codes that have been replaced by new or expanded codes, the
corresponding new or expanded diagnosis codes are included in Table 6A
(New Diagnosis Codes). New procedure codes are shown in Table 6B. Table
6C contains invalid diagnosis codes, and Table 6D contains invalid
procedure codes. Revisions to diagnosis code titles are in Table 6E
(Revised Diagnosis Code Titles), which also include the DRG assignments
for these revised codes. Revisions to procedure code titles are in
Table 6F (Revised Procedure Codes Titles).
In September 2000, the Department implemented a policy of paying
for inpatient hospital stays for Medicare beneficiaries participating
in clinical trials (HCFA Program Memorandum AB 00-89, September 19,
2000). Hospitals were encouraged to identify the patients involved by
reporting an ICD-9-CM code. This would allow the examination of data on
the patients involved in clinical trials. However, there was no clear
ICD-9-CM diagnosis code for patients who took part in a clinical trial.
There was a code for patients receiving an examination as part of the
control group for clinical trials. This control group code was V70.7
(Examination for normal comparison or control in clinical research).
Hospitals were instructed to use V70.5 (Health examination of defined
subpopulations), for patients participating in a clinical trial.
This coding directive has created some confusion because of the
title and description of the two codes. Hospitals also have requested
that all clinical patients be captured under one code. They indicated
that the use of one code
[[Page 39855]]
would be especially useful because patients frequently do not know if
they are part of the control group or are receiving new therapy.
To help alleviate the confusion, the ICD-9-CM Coordination and
Maintenance Committee revised code V70.7. Effective October 1, 2001,
the new title of code V70.7 is ``Examination of patient in clinical
trial.'' This revision will make it easier to capture data on Medicare
beneficiaries who are participating in a clinical trial.
Comment: One commenter questioned the DRG assignment of 525.12
(Loss of teeth due to periodontal disease) listed in Table 6A of the
Addendum of the proposed rule. Table 6A in the proposed rule listed the
proposed DRG assignments within MDC 3 for this new code as DRGs 182,
183, and 184. The commenter stated that the DRG assignments within MDC
3 should actually be DRGs 185, 186, and 187, since these were the DRGs
used for its predecessor code, 525.1. The commenter also pointed out
that the other new codes within this category (525.10-525.19) were
assigned to DRGs 185, 186, and 187.
Response: The commenter is correct. We are assigning code 525.12 to
DRGs 185, 186, and 187 within MDC 3. This is consistent with the way
the other codes in the new category were assigned. In this final rule,
we are correcting Table 6A to show that 525.12 is assigned to DRGs 185,
186, and 187 within MDC 3.
13. Other Issues
a. Pancreas Transplant
Effective July 1, 1999, Medicare covers whole organ pancreas
transplantation if the transplantation is performed simultaneously with
or after a kidney transplant (procedure codes 55.69 (Other kidney
transplantation), or diagnosis code V42.0 (Organ or tissue replaced by
transplant, Kidney), along with 52.80 (Pancreatic transplant, not
otherwise specified), or 52.82 (Homotransplant of pancreas)). A
discussion of the history of these coverage decisions and codes can be
found in the August 1, 2000 final rule on the prospective payment
system for FY 2001 (65 FR 47067).
We discussed the appropriate DRG classification for these cases in
both the July 30, 1999 final rule (64 FR 41497) and the August 1, 2000
final rule (65 FR 47067). Currently, cases can be assigned to one of
two major DRGs depending on principal diagnosis. 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 cases will
be assigned to DRG 302 (Kidney Transplant). If a pancreas transplant is
performed following a kidney transplant (during a different hospital
admission) on a patient with chronic renal failure secondary to
diabetes with renal manifestations, the case is assigned to DRG 468
(Extensive OR Procedure Unrelated to Principal Diagnosis). This is
because pancreas transplant is not assigned to MDC 11 (Diseases and
Disorders of the Kidney and Urinary Tract), the MDC to which a
principal diagnosis of chronic renal failure secondary to diabetes is
assigned.
In the August 1, 2000 final rule, we noted that we would continue
to monitor these transplant cases to determine the appropriateness of
establishing a new DRG. For the May 4 proposed rule, using data in the
FY 2000 MedPAR file (updated through May 31, 2000), we analyzed the
cases for which procedure codes 52.80 and 52.82 were reported. (Our
data showed that 15 of the cases were coded using 52.83
(Heterotransplant of pancreas), which is not a covered procedure under
any circumstances.) We identified a total of 221 cases for this time
period. The United Network for Organ Sharing (UNOS) reported it had
identified 270 cases through September 2000.
These 221 MedPAR cases were distributed over 6 DRGs, with the
majority (158 cases or 72 percent) assigned to DRG 302, and 23 cases
(10 percent) assigned to DRG 468. The remaining 40 cases were
distributed between 4 other DRGs, with the majority (25 cases) being
assigned to DRG 292 (Other Endocrine, Nutritional and Metabolic OR
Procedures with CC). Four cases were assigned to DRG 483 (Tracheostomy
with Principal Diagnosis except Face, Mouth and Neck Diagnoses) in the
Pre-MDC grouping, which took precedence over any other DRG assignment.
We arrayed the data based on the presence or absence of kidney
transplant; that is, pancreas transplant codes with or without 55.69.
The majority of cases (166 or 75 percent) had the combined kidney-
pancreas transplant in one operative episode, with 55 (25 percent) of
the cases having pancreas transplant subsequent to the kidney
transplant. Differences in hospital charges were significantly higher
for a pancreas transplant plus a kidney transplant ($138,809) than a
pancreas transplant alone ($85,972), and both were higher than average
standardized charges in DRG 302 ($64,760) or DRG 468 ($39,707),
although it must be noted that these figures do reflect the resource
intensive patients assigned to DRG 483. Those patients in DRG 483 had
average standardized charges of $377,934.
Because these categories of patients do not fit into existing DRGs
from either a clinical or resource perspective, in the May 4 proposed
rule, we proposed to create two new DRGs that would reflect these
patients' unique clinical profiles: DRG 512 (Simultaneous Pancreas/
Kidney Transplant) and DRG 513 (Pancreas Transplants). Cases grouped to
either DRGs 512 or 513 must have a principal or secondary diagnosis
code and procedure code or combination of procedure codes as indicated
in the chart below:
Composition of Proposed DRGs 512 and 513
----------------------------------------------------------------------------------------------------------------
Included in Included in
Diagnosis and procedure codes DRG 512 DRG 513
----------------------------------------------------------------------------------------------------------------
Principal or Secondary ICD-9-CM Diabetes Mellitus Code:
250.00 Diabetes mellitus without mention of complication, Type II or X X
unspecified type, not as stated as uncontrolled..........................
250.01 Diabetes mellitus without mention of complication, Type I, not X X
stated as uncontrolled...................................................
250.02 Diabetes mellitus without mention of complication, Type II or X X
unspecified type, uncontrolled...........................................
250.03 Diabetes mellitus without mention of complication, Type I, X X
uncontrolled.............................................................
250.10 Diabetes with ketoacidosis, Type II or Unspecified type, not X X
stated as uncontrolled...................................................
250.11 Diabetes with ketoacidosis, Type I, not stated as uncontrolled.... X X
250.12 Diabetes with ketoacidosis, Type II or unspecified type, X X
uncontrolled.............................................................
250.13 Diabetes with ketoacidosis, Type I, controlled.................... X X
250.20 Diabetes with hyperosmolarity, Type II or unspecified type, not X X
stated as uncontrolled...................................................
250.21 Diabetes with hyperosmolarity, Type I, not stated as uncontrolled. X X
[[Page 39856]]
250.22 Diabetes with hyperosmolarity, Type II or unspecified type, X X
uncontrolled.............................................................
250.23 Diabetes with hyperosmolarity, Type I, uncontrolled............... X X
250.30 Diabetes with other coma, Type II or unspecified type, not stated X X
as uncontrolled..........................................................
250.31 Diabetes with other coma, Type I, not stated as uncontrolled...... X X
250.32 Diabetes with other coma, Type II or unspecified type, X X
uncontrolled.............................................................
250.33 Diabetes with other coma, Type I, uncontrolled.................... X X
250.40 Diabetes with renal manifestations, Type II or unspecified type, X X
not stated as uncontrolled...............................................
250.41 Diabetes with renal manifestations, Type I, not stated as X X
uncontrolled.............................................................
250.42 Diabetes with renal manifestations, Type II or unspecified type, X X
uncontrolled.............................................................
250.43 Diabetes with renal manifestations, Type I, uncontrolled.......... X X
250.50 Diabetes with ophthalmic manifestations, Type II or unspecified X X
type, not stated as uncontrolled.........................................
250.51 Diabetes with ophthalmic manifestations, Type I, not stated as X X
uncontrolled.............................................................
250.52 Diabetes with ophthalmic manifestations, Type II or unspecified X X
type, uncontrolled.......................................................
250.53 Diabetes with ophthalmic manifestations, Type I, uncontrolled..... X X
250.60 Diabetes with neurological manifestations, Type II or unspecified X X
type, not stated as uncontrolled.........................................
250.61 Diabetes with neurological manifestations, Type I, not stated as X X
uncontrolled.............................................................
250.62 Diabetes with neurological manifestations, Type II or unspecified X X
type, uncontrolled.......................................................
250.63 Diabetes with neurological manifestations, Type I uncontrolled.... X X
250.70 Diabetes with peripheral circulatory disorders, Type II or X X
unspecified type, not stated as uncontrolled.............................
250.71 Diabetes with peripheral circulatory disorders, Type I, not stated X X
as uncontrolled..........................................................
250.72 Diabetes with peripheral circulatory disorders, Type II or X X
unspecified type, uncontrolled...........................................
250.73 Diabetes with peripheral circulatory disorders, Type I, X X
uncontrolled.............................................................
250.80 Diabetes with other specified manifestations, Type II or X X
unspecified type, not stated as uncontrolled.............................
250.81 Diabetes with other specified manifestations, Type I, not states X X
as uncontrolled..........................................................
250.82 Diabetes with other specified manifestations, Type II or X X
unspecified type, uncontrolled...........................................
250.83 Diabetes with other specified manifestations, Type I, uncontrolled X X
250.90 Diabetes with unspecified complication, Type II or unspecified X X
type, not states as uncontrolled.........................................
250.91 Diabetes with unspecified complication, Type I, not stated as X X
uncontrolled.............................................................
250.92 Diabetes with unspecified complication, Type II or unspecified X X
type, uncontrolled.......................................................
250.93 Diabetes with unspecified complication, Type I, uncontrolled...... X X
Principal or Secondary Diagnosis Code:
585 Chronic renal failure................................................ X X
403.01 Hypertensive renal disease, malignant, with renal failure......... X X
403.11 Hypertensive renal disease, benign, with renal failure............ X X
403.91 Hypertensive renal disease, unspecified, with renal failure....... X X
404.02 Hypertensive heart & renal disease, malignant, with renal failure. X X
404.03 Hypertensive heart & renal disease, malignant, with congestive X X
heart failure and renal disease..........................................
404.12 Hypertensive heart & renal disease, benign, with renal failure.... X X
404.13 Hypertensive heart & renal disease, benign, with congestive heart X X
failure and renal disease................................................
404.92 Hypertensive heart & renal disease, unspecified, with renal X X
failure..................................................................
404.93 Hypertensive heart & renal disease, unspecified, with congestive X X
heart failure and renal failure..........................................
V42.0 Organ or tissue replaced by transplant, kidney..................... X X
V43.89 Organ or tissue replaced by other means, other (Kidney)........... X X
Procedure Code:
52.80 Pancreatic transplant, not otherwise specified..................... ............... X
52.82 Homotransplant of pancreas......................................... ............... X
Combination Procedure Codes:
52.80 Pancreatic transplant, not otherwise specified,
Plus
55.69 Other kidney transplantation....................................... X ...............
Or
52.82 Homotransplant of pancreas
Plus
55.69 Other kidney transplantation....................................... X ...............
----------------------------------------------------------------------------------------------------------------
The logic for the DRG 512 accepts the pair of diagnosis codes in
any position (principal/secondary or secondary/secondary). The pair of
procedure codes must be present along with the two diagnosis codes.
This DRG will be placed in the Pre-MDC GROUPER logic immediately
following DRG 480 (Liver Transplant).
The logic for DRG 513 accepts the pair of diagnosis codes in any
position (principal/secondary or secondary/secondary). Only one
procedure code must be used along with the two diagnosis codes. This
DRG will be placed in the Pre-MDC GROUPER logic immediately following
new DRG 512 (Simultaneous Pancreas/Kidney Transplant).
We received two comments on this proposal. One commenter supported
the creation of the two new DRGs; a summary of the other comment
follows:
Comment: One commenter noted that, as pancreas transplants were
approved by Medicare on July 1, 1999, a special billing procedure
should be made available to hospitals to enable hospitals to bill for
the transplant DRG back to the effective date of the covered service.
Response: DRGs 512 and 513 are effective for discharges occurring
on or
[[Page 39857]]
after October 1, 2001, for FY 2002. Discharges involving pancreas
transplants occurring prior to that time are assigned to existing DRGs
as described above. Therefore, there is no need for hospitals to
resubmit their bills.
We are adopting the establishment of proposed DRGs 512 and 513 as
final.
b. Intestinal Transplantation
Effective April 1, 2001, Medicare covers intestinal transplantation
for the purpose of restoring intestinal function in patients with
irreversible intestinal failure (Medicare Program Memorandum
Transmittal No. AB-01-58, April 12, 2001). This procedure is covered
only when performed for patients who have failed total parenteral
nutrition (TPN) and only when performed in centers that meet approval
criteria.
Intestinal failure is defined as the loss of absorptive capacity of
the small bowel secondary to severe primary gastrointestinal disease or
surgically induced short bowel syndrome. Intestinal failure prevents
oral nutrition and may be associated with both mortality and profound
morbidity.
If an intestinal transplantation alone is performed on a patient
with an intestinal principal diagnosis, the case would be assigned to
either DRG 148 (Major Small & Large Bowel Procedures With CC) or DRG
149 (Major Small & Large Bowel Procedures Without CC). If an intestinal
transplantation and a liver transplantation are performed
simultaneously, the case would be assigned to DRG 480 (Liver
Transplant).
If an intestinal transplantation alone is performed on a patient
with an intestinal principal diagnosis, the case would be assigned to
either DRG 148 (Major Small & Large Bowel Procedures with CC) or DRG
149 (Major Small & Large Bowel Procedures Without CC). If an intestinal
transplantation and a liver transplantation are performed
simultaneously, the case would be assigned to DRG 480 (Liver
Transplant).
If an intestinal transplantation and a pancreas transplantation are
performed simultaneously, currently the case would be assigned to
either DRG 148 or DRG 149. Effective October 1, 2001, the case would be
assigned to DRG 513 (Pancreas Transplant). We proposed to make a
conforming change to the regulations at Sec. 412.2(e)(4) and
Sec. 486.302 to include intestines (and multivisceral organs) in the
list of organs for which Medicare pays for the acquisition costs on a
reasonable cost basis.
Effective October 1, 2000, procedure code 46.97 (Transplant of
intestine) was created. For the proposed rule, we examined our Medicare
claims data to determine whether it was appropriate to propose a new
intestinal transplant DRG. We examined data in the FY 2000 MedPAR file
containing bills submitted through May 31, 2000. Because procedure code
46.97 was not in place during this time we focused our examination on
the previous code assignment for intestinal transplant, code 46.99
(Other operations on intestines), and facilities that are currently
performing intestinal transplantation. We were able to identify only
one case, with an average charge of approximately $10,738 as compared
to the average standardized charges for DRGs 148 and 149, which are
approximately $37,961, and $16,965, respectively. We will continue to
monitor these cases to determine whether it may be appropriate in the
future to establish a new DRG.
Comment: One commenter recommended performing data analysis next
year to determine if a separate intestinal transplantation DRG should
be created based on the fact that these procedures are being performed
on a more frequent basis. Another commenter suggested that the preamble
specifically state that while the acquisition costs for heart, liver,
lung, and pancreas transplants continue to be paid on a reasonable cost
basis, the acquisition costs for intestinal transplantation will be
paid through the hospital inpatient prospective payment system DRG
payment mechanism.
Response: It is our intent to continue to monitor these cases to
determine whether it may be appropriate in the future to establish a
new DRG.
To clarify the issue of acquisition costs, Medicare Program
Memorandum Transmittal No. AB-01-58, released April 12, 2001, states
that Medicare will not pay transplant facilities on a reasonable cost
basis for organ acquisition for intestinal or multivisceral
transplants. The DRG payment will be payment in full for hospital
services related to this procedure. However, in this final rule, we are
implementing a conforming change to the regulations at Sec. 412.2(e)(4)
and Sec. 486.302, to include intestines (and multivisceral organs) in
the list of organs for which Medicare pays for the acquisition costs on
a reasonable cost basis. This change is effective with acquisition
costs incurred on or after October 1, 2001. After that date, costs
associated with the acquisition of intestines and multivisceral organs
will be paid on a reasonable cost basis. Costs associated with
intestines procured separately will be allocated to an intestine cost
center and allocated on Worksheet D-6. Multivisceral organ
transplantation includes organs in the digestive system (that is,
stomach, duodenum, pancreas, liver, intestine, and colon).
Multivisceral procurements, including an organ(s) as defined at
Sec. 486.302 as well as the intestine (small bowel), will be allocated
to the intestinal acquisition cost center. Multivisceral procurements
are procured en bloc and the entire cost of procuring all of the organs
will be allocated to the intestinal acquisition cost center.
c. Payment for Blood Clotting Factor Administered to Hemophilia
Inpatients
Comment: Although this issue was not addressed in the proposed
rule, we received one comment requesting that the add-on payment for
blood clotting factors administered to hemophilia inpatients include
adequate reimbursement for hospitals that treat beneficiaries with
acquired hemophilia.
Response: According to section 4452 of Public Law 105-33, which
amended section 6011(d) of Public Law 101-239, prospective payment
hospitals receive an additional payment for costs of administering
blood clotting factor to Medicare hemophiliacs who are hospital
inpatients.
Hemophilia, a bleeding disorder characterized by prolonged clotting
time, is caused by a deficiency of a factor necessary for blood to
clot. In the August 29, 1997 final rule implementing section 4452 of
Public Law 105-33 (62 FR 46002), we stated that hemophilia was
considered to encompass the following conditions: Factor VIII
deficiency (classical hemophilia); Factor IX deficiency (also termed
plasma thromboplastin component (PTC) or Christmas factor deficiency);
and Von Willebrand's disease. The most common factors required by
hemophiliacs to increase coagulation are Factor VIII and Factor IX; a
small number of hemophiliacs have developed inhibitors to these factors
and require special treatment. We did not receive any comments
regarding this coverage until, most recently, the cases of acquired
hemophilia, which affects a small subset of individuals (1 in 1
million), were brought to our attention.
We are revising our claims processing instructions to permit add-on
payments for the following ICD-9-CM diagnosis codes associated with
acquired hemophilia:
286.5 Hemorrhagic disorder due to circulating anticoagulants
286.7 Acquired coagulation factor deficiency.
[[Page 39858]]
C. Recalibration of DRG Weights
We proposed to use the same basic methodology for the FY 2002
recalibration as we did for FY 2001 (August 1, 2000 final rule (65 FR
47069)). That is, we would recalibrate the weights based on charge data
for Medicare discharges. However, we proposed to use the most current
charge information available, the FY 2000 MedPAR file. (For the FY 2001
recalibration, we used the FY 1999 MedPAR file.) The MedPAR file is
based on fully coded diagnostic and procedure data for all Medicare
inpatient hospital bills.
The final recalibrated DRG relative weights are constructed from FY
2000 MedPAR data (discharges occurring between October 1, 1999 and
September 30, 2000), based on bills received by CMS through March 31,
2001, from all hospitals subject to the prospective payment system and
short-term acute care hospitals in waiver States. The FY 2000 MedPAR
file includes data for approximately 11,094,323 Medicare discharges.
The methodology used to calculate the DRG relative weights from the
FY 2000 MedPAR file is as follows:
To the extent possible, all the claims were regrouped
using the DRG classification revisions discussed in section II.B. of
this preamble.
Charges were standardized to remove the effects of
differences in area wage levels, indirect medical education and
disproportionate share payments, and, for hospitals in Alaska and
Hawaii, the applicable cost-of-living adjustment.
The average standardized charge per DRG was calculated by
summing the standardized charges for all cases in the DRG and dividing
that amount by the number of cases classified in the DRG.
We then eliminated statistical outliers, using the same
criteria 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 are eliminated.
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 transfer payment under the per diem payment methodology to the
full DRG payment for nontransfer cases. That is, transfer cases paid
under the transfer methodology equal to half of what the case would
receive as a nontransfer would be 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 1999 MedPAR file.
(Medicare coverage for heart, heart-lung, liver, and lung transplants
is limited to those facilities that have received approval from CMS as
transplant centers.)
Acquisition costs for kidney, heart, heart-lung, liver,
lung, and pancreas 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); DRG 480 (Liver Transplant); DRG 495 (Lung
Transplant); and proposed new DRGs 512 (Simultaneous Pancreas/Kidney
Transplant) and 513 (Pancreas 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 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 use that same case threshold in
recalibrating the DRG weights for FY 2002. Using the FY 2000 MedPAR
data set, there are 37 DRGs that contain fewer than 10 cases. We
computed the weights for these 37 low-volume DRGs by adjusting the FY
2001 weights of these DRGs by the percentage change in the average
weight of the cases in the other DRGs.
The new weights are normalized by an adjustment factor (1.44556) 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, and accounts for
the gradual shift in cases toward higher-weighted DRGs over time.
We received no comments on DRG recalibration.
Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with
FY 1991, reclassification and recalibration changes be made in a manner
that assures that the aggregate payments are neither greater than nor
less than the aggregate payments that would have been made without the
changes. Although normalization is intended to achieve this effect,
equating the average case weight after recalibration to the average
case weight before recalibration does not necessarily achieve budget
neutrality with respect to aggregate payments to hospitals because
payment to hospitals is affected by factors other than average case
weight. Therefore, as we have done in past years and as discussed in
section II.A.4.a. of the Addendum to the 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.
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). The OMB also designates Consolidated MSAs
(CMSAs). A CMSA is a metropolitan area with a population of one million
or more, comprising 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. For purposes of the
wage index, we combine all of the rural counties in a State to
calculate a rural wage index for that State.
We note that, effective April 1, 1990, the term Metropolitan Area
(MA) replaced the term MSA (which had been used since June 30, 1983) to
describe the set of metropolitan areas consisting of MSAs, PMSAs, and
CMSAs. The terminology was changed by OMB in
[[Page 39859]]
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 2002 Wage Index Update
The FY 2002 wage index values in section V of the Addendum to this
final rule (effective for hospital discharges occurring on or after
October 1, 2001 and before October 1, 2002) are based on the data
collected from the Medicare cost reports submitted by hospitals for
cost reporting periods beginning in FY 1998 (the FY 2001 wage index was
based on FY 1997 wage data).
The final FY 2002 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 2001 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 2001, the wage
index for FY 2002 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 (SNF)
services, home health services, or other subprovider components that
are not subject to the prospective payment system.
We calculate a separate Puerto Rico-specific wage index and apply
it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.)
This wage index is based solely on Puerto Rico's data. Finally, section
4410 of Public Law 105-33 provides that, for discharges on or after
October 1, 1997, the area wage index applicable to any hospital that is
not located in a rural area may not be less than the area wage index
applicable to hospitals located in rural areas in that State.
C. FY 2002 Wage Index
Because the hospital wage index is used to adjust payments to
hospitals under the prospective payment system, the wage index should,
to the extent possible, reflect the wage costs associated with the
areas of the hospital included under the hospital inpatient prospective
payment system. In response to concerns within the hospital community
related to the removal, from the wage index calculation, of costs
related to graduate medical education (GME) (teaching physicians and
residents) and certified registered nurse anesthetists (CRNAs), which
are paid by Medicare separately from the prospective payment system,
the AHA convened a workgroup to develop a consensus recommendation on
this issue. The workgroup recommended that costs related to GME and
CRNAs 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 specified in the July 30,
1999 final rule (64 FR 41505) that we would phase-out these costs from
the calculation of the wage index over a 5-year period, beginning in FY
2000. In keeping with the decision to phase-out costs related to GME
and CRNAs, the final FY 2002 wage index is based on a blend of 40
percent of an average hourly wage including these costs, and 60 percent
of an average hourly wage excluding these costs.
Beginning with the FY 1998 cost reports, we revised the Worksheet
S-3, Part II so that hospitals can separately report teaching physician
Part A costs on lines 4.01, 10.01, 12.01, and 18.01. Therefore, it is
no longer necessary for us to conduct the special survey we used for
the FY 2000 and FY 2001 wage indexes (64 FR 41505 and 65 FR 47071).
1. Health Insurance and Health-Related Costs
In the August 1, 2000 final rule, we clarified our definition of
``purchased health insurance costs'' and ``self-insurance'' for
hospitals that provide health insurance to employees (65 FR 47073). For
purposes of the wage index, purchased or self-funded health insurance
plan costs include the hospitals' insurance premium costs, external
administration costs, and the share of costs for services delivered to
employees.
In response to a comment received concerning this issue, we stated
that, for self-funded health insurance costs, personnel costs
associated with hospital staff that deliver the services to the
employees must continue to be excluded from wage-related costs if the
costs are already included in the wage data as salaries on Worksheet S-
3, Part II, Line 1. However, after further consideration of this
policy, particularly with respect to concerns expressed by our fiscal
intermediaries about the level of effort required during the wage index
desk review process to ensure hospitals are appropriately identifying
and excluding these costs, in the May 4, 2001 proposed rule we proposed
a revision. Effective with the calculation of the FY 2003 wage index,
for either purchased or self-funded health insurance, we proposed to
allow personnel costs associated with hospital staff who deliver
services to employees to be included as part of the wage-related costs.
We believe the proposed revised policy will ensure that health
insurance costs are consistently reported by hospitals. Health
insurance costs would continue to be developed using generally accepted
accounting principles.
In the August 1, 2000 final rule (65 FR 47073), we further
clarified that health-related costs (including employee physical
examinations, flu shots, and clinic visits, and other services that are
not covered by employees' health insurance plans but are provided at no
cost or at discounted rates to employees of the hospital) may be
included as ``other'' wage-related costs if, among other criteria, the
combined cost of all such health-related costs is greater than one
percent of the hospital's total salaries (less excluded area salaries).
For purposes of calculating the FY 2003 wage index (which will be
based on data for cost reporting periods beginning in FY 1999), we
proposed to revise this policy to allow hospitals to include health-
related costs as allowable core wage-related costs.
Comment: One commenter supported our proposal to include health-
related costs as core wage-related costs. The commenter also agreed
with our proposal to include all personnel costs associated with
hospital staff who deliver health services to employees. However, the
commenter expressed concern that the proposed changes would require
burdensome and duplicative revisions to cost reports that have already
been filed.
Response: We believe that these revised policies (to eliminate the
[[Page 39860]]
distinction between purchased health insurance and self-funded health
insurance, and to treat costs associated with health-related services
that are not part of the employees' health insurance plan consistent
with costs included in the plan) will ensure that these costs are
treated consistently across hospitals and fiscal intermediaries.
In response to the commenter's concern that the policy will require
revisions to previously submitted cost reports, we believe the changes
are not significant, particularly in light of the volume of changes
submitted every year by hospitals during the wage data review process
(see discussion in section III.G. of this final rule). The cost report
changes necessary to implement these policy changes involve including
costs previously disallowed. In the case of personnel costs associated
with hospital staff who deliver services to employees, these costs
would have already been identified in order to be excluded from the
wage data. With respect to health services provided outside the
employees' health insurance plan, we acknowledge that some hospitals
may not have tracked these costs because they did not qualify for
inclusion as other wage-related costs. However, due to concerns
expressed by fiscal intermediaries about the difficulty of identifying
these costs separate from those that are part of the insurance plan, we
believe there may be inconsistencies in the current data with regard to
how these costs are treated. Therefore, we believe, in the interest of
improving the consistency of the data, that we should begin to allow
these costs as core wage-related costs effective with the FY 2003 wage
index.
2. Costs of Contracted Pharmacy and Laboratory Services
Our policy concerning inclusion of contract labor costs for
purposes of calculating the wage index has evolved over the years. We
recognize the role of contract labor in meeting special personnel needs
of many hospitals. In addition, improvements in the wage data have
allowed us to more accurately identify contract labor costs and hours.
As a result, effective with the FY 1994 wage index, we included the
costs of direct patient care contract services in the wage index
calculation. The FY 1999 wage index included the costs and hours of
certain management contract services, and the FY 2000 wage index
included the costs for contract physician Part A services. (The 1996
proposed rule (61 FR 27456) provided an in-depth background to the
issues related to the inclusion of contract labor costs in the wage
index calculation.)
We revised the 1998 cost report to collect the data associated with
contract pharmacy, Worksheet S-3, Part II, Line 9.01, and contract
laboratory, Worksheet S-3, Part II, Line 9.02. The cost reporting
instructions for these line numbers followed that for all contract
labor lines; that is, to include the amount paid for services furnished
under contract for direct patient care, and not include cost for
equipment, supplies, travel expenses, and other miscellaneous or
overhead items (Medicare Provider Reimbursement Manual, Part 2, Cost
Reporting Forms and Instructions, Chapter 36, Transmittal 6, pages 36-
32). Effective with the FY 2002 wage index, which uses FY 1998 wage
data, we are including in this final rule (as proposed in the May 4
proposed rule) the costs and hours of contract pharmacy and laboratory
services.
Comment: Two commenters supported our proposed policy to include
the costs and hours of contract pharmacy and laboratory as direct
patient care contract labor in the FY 2002 wage index. However, both
commenters recommended that clearer guidelines be provided to ensure
consistency in interpretation by fiscal intermediaries and contract
vendors.
Response: Beginning with the FY 2002 wage index, we are including
the costs and hours of contract pharmacy and laboratory services in the
calculation of the wage index. Further instructions for reporting
contract pharmacy and laboratory costs will be included in Transmittal
8 of the cost report, due for release in early fall 2001.
3. Collection of Occupational Mix Data
Section 304(c) of Public Law 106-554 amended section 1886(d)(3)(E)
of the Act to require that the Secretary must provide for the
collection of data every 3 years on the occupational mix of employees
for each short-term, acute care hospital participating in the Medicare
program, in order to construct an occupational mix adjustment to the
wage index. The initial collection of these data must be completed by
September 30, 2003, for application beginning October 1, 2004.
Currently, the wage data collected on the cost report reflect the
sum of wages, hours, and wage-related costs for all hospital employees.
There is no separate collection by occupational categories of
employees, such as registered nurses or physical therapists. Total
salaries and hours reflect management decisions made by hospitals in
terms of how many employees within a certain occupation to employ to
treat different types of patients. For example, a large academic
medical center may tend to hire more high-cost specialized employees to
treat its more acutely ill patient population. The argument is that the
higher labor costs incurred to treat this patient population are
reflected in the higher case mix of these hospitals, and therefore,
reflecting these costs in the wage index is essentially counting them
twice.
An occupational mix adjustment can be used to account for hospital
management decisions about how many employees to hire in each
occupational category. Occupational mix data measure the price the
hospital must pay for employees within each category. A wage index that
reflected only these market prices would remove the impact of
management decisions about the mix of employees needed and, therefore,
better capture geographic variations in the labor market.
We have examined this issue previously. In the May 27, 1994 Federal
Register (59 FR 27724), we discussed the outcome of consideration of
this issue by a hospital workgroup. At that time, the workgroup's
consensus was that the data required to implement an occupational mix
adjustment were not available and the likelihood of obtaining such data
would be minimal. There seemed to be little support among hospital
industry representatives for developing a system that would create
additional reporting burdens with an unproven or minimal impact on the
distribution of payments. Also, in the August 30, 1991 Federal Register
(56 FR 43219), we stated our belief that the collection of these data
would be costly and difficult.
In considering the format to collect occupational mix data, we
looked to data currently being collected by the Bureau of Labor
Statistics (BLS), which conducts an annual mail survey to produce
estimates of employment and wages for specific occupations. This
program, Occupational Employment Statistics (OES), collects data on
wage and salary workers in nonfarm establishments in order to produce
employment and wage estimates for over 700 occupations.
The OES survey collects wage data in 12 hourly rate intervals.
Employers report the number of employees in an occupation per each wage
range. To illustrate, the wage intervals used for the 1999 survey are
as follows:
[[Page 39861]]
----------------------------------------------------------------------------------------------------------------
Interval Hourly wages Annual wages
----------------------------------------------------------------------------------------------------------------
Range A................................ Under $6.75.................... Under $14,040.
Range B................................ $6.75 to $8.49................. $14,040 to $17,659.
Range C................................ 8.50 to 10.74.................. 17,660 to 22,359.
Range D................................ 10.75 to 13.49................. 22,360 to 28,079.
Range E................................ 13.50 to 16.99................. 28,080 to 35,359.
Range F................................ 17.00 to 21.49................. 35,360 to 44,719.
Range G................................ 21.50 to 27.24................. 44,720 to 56,679.
Range H................................ 27.25 to 34.49................. 56,680 to 71,759.
Range I................................ 34.50 to 43.74................. 71,760 to 90,999.
Range J................................ 43.75 to 55.49................. 91,000 to 115,439.
Range K................................ 55.50 to 69.99................. 115,440 to 145,599.
Range L................................ 70.00 and over................. 145,600 and over.
----------------------------------------------------------------------------------------------------------------
We noted that this table is for illustrative purposes, and that we
may update the data ranges in our actual collection instrument.
Although we initially considered using the OES data, section 304(c)
of Public Law 106-554 requires us to collect data from every short-
term, acute care hospital. The OES data are a sample survey and,
therefore, as currently conducted, are not consistent with the
statutory requirement to include data from every hospital. Another
issue with using OES data is that, for purposes of the Medicare wage
index, the hospitals' data must be reviewed and verified by the fiscal
intermediaries. The OES survey is a voluntary survey for most States.
Although we decided to pursue a separate data collection effort
than OES, we proposed in the May 4, 2001 proposed rule to model our
format after the one used by OES. In this way, hospitals participating
in the OES survey would have no additional recordkeeping and reporting
requirements beyond those of the OES survey.
The OES survey of the hospital industry is designed to capture all
occupational categories within the industry. For purposes of adjusting
the wage index for occupational mix, we do not believe it is necessary
to collect data from such a comprehensive scope of categories.
Furthermore, because the data must be audited, a comprehensive list of
categories would be excessively burdensome.
In deciding which occupational categories to include, we reviewed
the occupational categories collected by OES and identified those with
at least 35,000 hospital employees. Our goal is to collect data from a
sample of occupational categories that provides a valid measure of wage
rates within a geographical area. In the May 4 proposed rule, using
this threshold of at least 35,000 employees within a category
nationally, we proposed to collect data on the number of employees by
wage range as illustrated in the above table, for the occupational
categories listed below. The following data, which was also listed in
the proposed rule, are based on the 1998 OES survey. (These data are no
longer available on the internet.)
----------------------------------------------------------------------------------------------------------------
Percent of
Number of total Mean
OES code Category employees hospital hourly
employees wage
----------------------------------------------------------------------------------------------------------------
15008.................................. Medicine and Health Services 93,680 1.9 $27.38
Manager.
27302.................................. Social Workers, Medical and 53,360 1.1 16.33
Psychiatric.
32102.................................. Physicians and Surgeons........ 125,640 2.6 43.76
32308.................................. Physical Therapists............ 39,840 0.8 26.14
32502.................................. Registered Nurses.............. 1,231,980 25.0 21.12
32505.................................. Licensed Practical Nurses...... 206,360 4.2 13.39
32517.................................. Pharmacists.................... 46,860 1.0 28.62
32911, 32928, and 32931................ Clinical Technologists and 122,380 2.50 11.69
Technicians.
51002, 55105, 55108, 55305, 55332, and First-Line Supervisors and 445,730 9.5 11.39
55347. Clerical Workers.
65038, 67002, and 67005................ Food Preparation Workers and 218,440 4.5 8.17
Housekeeping.
66008.................................. Nursing Aides, Orderlies, and 301,240 6.2 8.67
Attendants.
----------------------------------------------------------------------------------------------------------------
We proposed that this list of occupational categories provides a
good representation of the employee mix at most hospitals. It has since
come to our attention that the occupational categories listed in the
proposed rule have been replaced by Standard Occupational Category
definitions.
Because we had not yet settled on the methodology to use the
occupational mix data in the wage index, we discussed in the proposed
rule one option to weight each hospital's wage index by its
occupational mix index. This requires calculating a national
occupational mix index and then breaking it down by MSA and by
hospital, similar to how the wage index is broken down. In this way,
the wage index would capture geographic differences in wage rates. The
decision about how to apply the occupational mix index to the wage
index depends on the quality of the data collected, since this effort
will be the first time wage and hour data by occupation are collected
in this audited manner.
Section 304(c) directs the Secretary to provide for the collection
of these data by September 30, 2003, and to apply them in the wage
index by October 1, 2004. Therefore, the data are to be incorporated in
the FY 2005 wage index. Under our current timetable, the FY 2005 wage
index will be based on wage data collected from hospitals' cost
reporting periods beginning during FY 2001. In order to facilitate the
fiscal intermediaries' review of these data, we believe the
occupational mix data should coincide with the data otherwise
[[Page 39862]]
used to calculate the cost report. Therefore, we will conduct a special
survey of all short-term acute-care hospitals that are required to
report wage data to collect these data coinciding with hospitals' FY
2001 cost reports.
Comment: Several commenters expressed interest in working with us
to develop an appropriate data collection tool. They suggested that the
data be relatively simple for hospitals to gather and submit, and
should be collected on 100 percent of hospital employees. Another
commenter recommended that, at least initially, only data on nursing
categories would be sufficient since nurses are 35 percent of hospital
employees and can be divided into a few easily distinguishable
categories. Two commenters offered examples for how these data are
collected in their area. Some commenters wanted these data incorporated
in the cost report to limit the number of forms hospitals must complete
and to improve the response rate.
Response: We agree that it would be beneficial to work with the
industry to develop a workable data collection tool, especially given
the importance of the wage index in adjusting hospital payments. We
appreciate the comments on the option presented in the proposed rule
and believe that these comments will help initiate further thought
toward the development of an occupational mix survey that can be
administered without excessive burden on hospitals, the fiscal
intermediaries, or CMS.
Due to time constraints in meeting the statutory deadlines, our
intention at this point is to attempt to develop a survey instrument
for the initial collection of occupational mix data that can be used by
hospitals during calendar year 2002. Therefore, prior to January 1,
2002, we plan to work with the hospital community to develop a survey
instrument. We believe issues related to the sample size of the data
collected and the appropriate occupational categories to collect can
best be resolved through consultation with the industry. Therefore, we
will be contacting those organizations that expressed an interest in
consultation in their comments. Other interested parties are encouraged
to contact us as well.
After developing a method that appropriately balances the need to
collect accurate and reliable data with the need to collect data
hospitals can be reasonably expected to have available, we will issue
instructions as to the type of data to be collected, in advance of
actually requiring hospitals to begin providing the data.
Comment: Some commenters asked us to further develop the planned
use of the occupation information and then decide what information is
required. They requested that we publish the projected economic effects
of an occupational mix adjustment upon each hospital as soon as
feasible, and demonstrate tangible benefits prior to requiring
hospitals to collect data. One commenter offered a specific methodology
that could be employed. Other commenters want the methodology phased-in
over time to allow hospitals time to adjust to different payment
levels.
Response: In the proposed rule, we stated that we had not yet
settled on the actual methodology for using the occupational mix data
in the calculation of the wage index. We indicated the decision as to
how the data will be used is dependent on the quality of the data
collected. That is still the case. Furthermore, as discussed above, we
intend to develop an appropriate data collection instrument in
consultation with the hospital community. Therefore, until decisions
are made with regard to the specific data to be collected, we cannot
specify how the data will be used. However, the selection of an
appropriate methodology (including a possible phase-in) will be
influenced by analysis of the impacts of the method on hospital
payments.
Comment: Two commenters expressed concerns that adopting the
occupational mix adjustment for the wage index will lower the average
hourly wage of teaching hospitals because of their mix of highly
skilled, higher paid employees to treat patients with more complex
conditions. These commenters argued that implementation of the
occupational mix adjustment should proceed only in conjunction with the
adoption of severity-adjusted DRGs. These commenters wrote that the
current DRG system does not adequately recognize patient severity and
pay for the higher resource costs associated with complex patients, but
teaching hospitals can recoup some of these losses because their higher
employee skill mix is reflected in their average hourly wage.
Furthermore, one commenter countered the argument that the higher
labor costs incurred to treat a more severely ill patient population
are reflected in the higher case mix of these hospitals and, therefore,
reflecting these costs in the wage index is essentially counting them
twice. This commenter pointed out that, because the DRG weights are
based on hospital charges that are standardized by, among other
factors, the area wage index, the weights of tertiary care DRGs are
lower than they would be if the average charge per case were not first
standardized by the wage index. However, the commenter went on to state
that it is preferable to account for skill mix in the wage index rather
than the case-mix index.
Response: As we stated in the August 1, 2000 final rule (65 FR
47103), we agree that severity-adjusted DRGs have potential for
reducing discrepancies between payments and costs for individual cases
(60 FR 29246). We have stated that, prior to implementing severity-
adjusted DRGs, we would need specific legislative authority to offset
any significant anticipated increase in payments attributable to
changes in coding practices caused by significant changes to the DRG
classification system. Section 301 of Public Law 106-554 authorized the
Secretary to adjust the average standardized amounts if he determines
that DRG coding or classification changes are likely to result in a
change in aggregate payments. Therefore, based on this authority, we
are beginning to evaluate the potential for implementing severity-
adjusted DRGs. Because we are at the initial stages of that effort, we
cannot yet estimate when, or if, such implementation may occur.
However, we agree with these commenters' points that significant
changes to any of the adjustments under the prospective payment system
must be considered in light of the effects such changes may have to
other such adjustments.
Comment: One commenter interpreted our proposal to suggest that the
fiscal year for which the data will be collected will be closed by the
time the methodology and data requirements have been established.
Response: In the proposed rule, we indicated we would conduct a
special survey to collect these data to coincide with hospitals' cost
reports beginning during FY 2001. We do not intend to require hospitals
to retroactively adjust their payroll records to collect these data.
Therefore, given our intention to gather input from the industry prior
to designing the survey instrument, it likely will not be possible to
completely coincide the data collection period with hospitals' FY 2001
cost reports.
Although there may be some auditing benefits to having the data
overlap, this type of data is not routinely collected through the cost
reports, so that the auditing benefits of such overlap may be minimal.
In addition, there may be a benefit to collecting occupational mix for
a more recent period in terms of reflecting current trends, such as
higher wages paid to nurses during a shortage.
[[Page 39863]]
Comment: Other commenters raised specific technical concerns about
the occupational mix discussion in the proposed rule.
Response: Rather than respond individually at this time to
technical issues associated with the occupational mix discussion in the
proposed rule, we will address these issues through direct consultation
with the industry, as described above.
D. Verification of Wage Data From the Medicare Cost Report
The data for the FY 2002 wage index were obtained from Worksheet S-
3, Parts II and III of the FY 1998 Medicare cost reports. The data file
used to construct the wage index includes FY 1998 data submitted to us
as of July 2001. As in past years, we performed an intensive review of
the wage data, mostly through the use of edits designed to identify
aberrant data.
We asked our fiscal intermediaries to revise or verify data
elements that resulted in specific edit failures. The unresolved data
elements that were included in the calculation of the proposed FY 2002
wage index have been resolved and are reflected in the calculation of
the final FY 2002 wage index. We note that, as part of this process to
identify aberrant data and correct any errors prior to the calculation
of the final FY 2002 wage index, we notified by letter those hospitals
that were leading to large variations in the wage indexes of their
labor market areas compared to the FY 2001 wage index. These hospitals
were advised to review their data to identify the reason for the large
increases or decreases and notify their fiscal intermediary of any
necessary corrections.
Also, as part of our editing process, in the final wage index, we
removed data for 30 hospitals that failed edits. For 24 of these
hospitals, we were unable to obtain sufficient documentation to verify
or revise the data because the hospitals are no longer participating in
the Medicare program or are in bankruptcy status. Six hospitals had
incomplete or inaccurate data resulting in exceptionally large, zero,
or negative average hourly wages. Therefore, they were removed from the
calculation. As a result, the final FY 2002 wage index is calculated
based on FY 1998 wage data for 4,880 hospitals.
Comment: One commenter recommended that we incorporate additional
fatal edits in the cost reporting systems to eliminate obvious errors
on the Worksheet S-3 that result in incomplete or erroneous wage data
that are difficult to correct 4 years later.
Response: We do not agree with the recommendation of the commenter.
A separate desk review is performed for the wage index. The desk
review, combined with the level two edits, is sufficient to provide
fiscal intermediaries with information to identify discrepancies, such
as zero or negative average hourly wage or missing hours, that can be
resolved by the fiscal intermediary during the cost reporting process.
E. Computation of the FY 2002 Wage Index
We note a technical change to the FY 2002 calculation. For the FY
2001 wage index calculation, we initially proposed to subtract Line 13
of Worksheet S-3, Part III from total hours when determining the
excluded hours ratio used to estimate the amount of overhead attributed
to excluded areas (65 FR 26299). However, the formula resulted in large
and inappropriate increases in the average hourly wages for some
hospitals (65 FR 47074), particularly hospitals that have large
overhead and excluded area costs. Therefore, for the final FY 2001 wage
index calculation, we reverted to the FY 2000 excluded hours ratio
formula, which did not subtract Line 13.
Subsequently, we analyzed how the application of this formula
resulted in overstated average hourly wages for some hospitals and how
we could improve the overall accuracy of the overhead allocation
methodology. We became aware that the problem was not in the excluded
hours ratio formula. Rather, our wage index calculation did not also
remove the overhead wage-related costs associated with excluded areas,
an amount that must be estimated before it can be subtracted from the
calculation. The combined effect of applying the excluded hours ratio
formula, which appropriately removes salaries of lower-wage, overhead
employees, and not subtracting overhead wage-related costs associated
with excluded areas, resulted in overstated salary costs and average
hourly wages.
For the FY 2002 wage index calculation, we are applying the
excluded hours ratio formula that subtracts Part III, Line 13 from
total hours. Additionally, for the first time in the wage index
calculation, we estimated and subtracted overhead wage-related costs
allocated to excluded areas.
After we applied this new calculation, there were still a few
hospitals that experienced large increases in their average hourly
wages. The intermediaries verified that the hospitals' wage data were
accurate, so we kept the data in the wage index calculation. These
hospitals primarily function as SNFs, psychiatric hospitals, or
rehabilitation hospitals that have few acute care beds. The hospitals'
higher average hourly wages reflect the costs of the higher salaried
employees that remain in the wage index calculation after we subtract
the costs of excluded area and associated overhead employees.
The method used to compute the final FY 2002 wage index follows.
Step 1--As noted above, we based the FY 2002 wage index on wage
data reported on the FY 1998 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, 1997 and before October 1, 1998. In addition, we
included data from any hospital that had cost reporting periods
beginning before October 1997 and reported a cost reporting period
covering all of FY 1998. 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 1998 data. We note that, if a hospital
had more than one cost reporting period beginning during FY 1998 (for
example, a hospital had two short cost reporting periods beginning on
or after October 1, 1997 and before October 1, 1998), we included wage
data from only one of the cost reporting periods, the longest, in the
wage index calculation. If there was more than one cost reporting
period and the periods were equal in length, we included the wage data
from the latest period in the wage index calculation.
Step 2--Salaries--The method used to compute a hospital's average
hourly wage is a blend of 40 percent of the hospital's average hourly
wage including all GME and CRNA costs, and 60 percent of the hospital's
average hourly wage after eliminating all GME and CRNA costs.
In calculating a hospital's average salaries plus wage-related
costs, including all GME 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
[[Page 39864]]
subject to the inpatient 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, pharmacy, laboratory, and
physician Part A services (Lines 9, 9.01, 9.02, 10, and 10.01), home
office salaries and wage-related costs reported by the hospital on
Lines 11, 12, and 12.01, and nonexcluded area wage-related costs (Lines
13, 14, 16, 18, 18.01, and 20).
We note that contract labor and home office salaries for which no
corresponding hours are reported were not included. In addition, wage-
related costs for specific categories of employees (Lines 16, 18,
18.01, and 20) are excluded if no corresponding salaries are reported
for those employees (Lines 2, 4, 4.01, and 6, respectively).
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, Lines (4.01, 10.01, 12.01, and 18.01), 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 to areas of the hospital excluded from the wage index
calculation. 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 the sum of Part II, Lines 3, 5, 7, and Part III, Line 13
of Worksheet S-3). 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. Next, we computed the amounts of overhead
wage-related costs to be allocated to excluded areas using three steps:
(1) We determined the ratio of overhead hours (Part III, Line 13) to
revised hours (Line 1 minus the sum of Lines 3, 5, and 7); (2) we
computed overhead wage-related costs by multiplying the overhead hours
ratio by wage-related costs reported on Part II, Lines 13, 14, 16, 18,
18.01, and 20; and (3) we multiplied the computed overhead wage-related
costs by the above excluded area hours ratio. Finally, we subtracted
the computed overhead salaries, wage-related costs, and hours
associated with excluded areas from the total salaries (plus wage-
related costs) and hours derived in Steps 2 and 3. Using the above
method for computing overhead salaries, wage-related costs, and hours
to allocate to excluded areas, we also computed these costs excluding
all costs associated with GME and CRNAs (Lines 2, 4.01, 6, 10.01,
12.01, and 18.01).
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, 1997 through
April 15, 1999 for private industry hospital workers from the Bureau of
Labor Statistics' Compensation and Working Conditions. We use the ECI
because it reflects the price increase associated with total
compensation (salaries plus fringes) rather than just the increase in
salaries. In addition, the ECI includes managers as well as other
hospital workers. This methodology to compute the monthly update
factors uses actual quarterly ECI data and assures that the update
factors match the actual quarterly and annual percent changes. The
factors used to adjust the hospital's data were based on the midpoint
of the cost reporting period, as indicated below.
Midpoint of Cost Reporting Period
------------------------------------------------------------------------
After Before Adjustment factor
------------------------------------------------------------------------
10/14/97 11/15/97 1.03822
11/14/97 12/15/97 1.03561
12/14/97 01/15/98 1.03292
01/14/98 02/15/98 1.03048
02/14/98 03/15/98 1.02828
03/14/98 04/15/98 1.02621
04/14/98 05/15/98 1.02411
05/14/98 06/15/98 1.02200
06/14/98 07/15/98 1.01973
07/14/98 08/15/98 1.01714
08/14/98 09/15/98 1.01424
09/14/98 10/15/98 1.01137
10/14/98 11/15/98 1.00885
11/14/98 12/15/98 1.00669
12/14/98 01/15/99 1.00462
01/14/99 02/15/99 1.00239
02/14/99 03/15/99 1.00000
03/14/99 04/15/99 0.99746
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 1998 and ending December 31, 1998 is June 30, 1998. An
adjustment factor of 1.01973 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 1998 and covered a
period of less than 360 days or more than 370 days, we annualized the
data to reflect a 1-year cost report. Annualization is accomplished by
dividing the data by the number of days in the cost report and then
multiplying the results by 365.
Step 6--Each hospital was assigned to its appropriate urban or
rural labor market area before any reclassifications under section
1886(d)(8)(B) or section 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 (with and without GME and CRNA
costs) 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 2002 wage index is based on a blend of average
hourly wages, we then added 40 percent of the average hourly wage
calculated without removing GME and CRNA costs, and 60 percent of the
average hourly wage calculated with these costs excluded.
Step 8--We added the total adjusted salaries plus wage-related
costs obtained in Step 5 for all hospitals in the nation and then
divided the sum by the national sum of total hours from Step 4 to
arrive at a national average hourly wage (using the same blending
methodology described in Step 7). Using the data as described above,
the national average hourly wage is $22.3096.
Step 9--For each urban or rural labor market area, we calculated
the hospital wage index value by dividing the area average hourly wage
obtained in Step 7 by the national average hourly wage computed in Step
8.
Step 10--Following the process set forth above, we developed a
separate Puerto Rico-specific wage index for purposes of adjusting the
Puerto Rico standardized amounts. (The national Puerto Rico
standardized amount is adjusted by a wage index calculated for all
Puerto Rico labor market areas based on the national average hourly
wage as described above.) We added the total adjusted salaries plus
wage-related costs (as calculated in Step 5) for all hospitals in
Puerto Rico and divided the sum by the total hours for Puerto Rico (as
calculated in Step 4) to arrive at an overall average hourly wage of
$10.7529 for Puerto Rico. For each labor market area in Puerto Rico, we
calculated the
[[Page 39865]]
Puerto Rico-specific wage index value by dividing the area average
hourly wage (as calculated in Step 7) by the overall Puerto Rico
average hourly wage.
Step 11--Section 4410 of Public Law 105-33 provides that, for
discharges on or after October 1, 1997, the area wage index applicable
to any hospital that is located in an urban 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 2002, this change
affects 217 hospitals in 40 MSAs. The MSAs affected by this provision
are identified in Table 4A by a footnote.
F. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more MSAs are considered to be located in
one of the adjacent MSAs if certain standards are met. Under section
1886(d)(10) of the Act, the Medicare Geographic Classification Review
Board (MGCRB) considers applications by hospitals for geographic
reclassification for purposes of payment under the prospective payment
system.
1. Provisions of Public Law 106-554
Section 304 of Public Law 106-554 made changes to several
provisions of section 1886(d)(10) of the Act relating to hospital
reclassifications and the wage index:
Section 304(a) amended section 1886(d)(10)(D) of the Act
by adding a clause (v) to provide that, beginning with FY 2001, an
MGCRB decision on a hospital reclassification for purposes of the wage
index is effective for 3 years, unless the hospital elects to terminate
the reclassification. Section 304(a) also provides that the MGCRB must
use the 3 most recent years' average hourly wage data in evaluating a
hospital's reclassification application for FY 2003 and any succeeding
fiscal year (section 1886(d)(10)(D)(vi) of the Act).
Section 304(b) provides that, by October 1, 2001, the
Secretary must establish a mechanism under which a statewide entity may
apply to have all of the geographic areas in the State treated as a
single geographic area for purposes of computing and applying a single
wage index, for reclassifications beginning in FY 2003. Section 304(b)
further requires that if the Secretary applies a statewide wage index
to a State, an application under section 1886(d)(10) of the Act by an
individual hospital in that State would not be considered.
We address our policy proposals relating to implementation of these
three provisions of sections 304(a) and (b) of Public Law 106-554 in
section IV.G. of this final rule. The following discussion of the
revisions to the wage index based on hospital redesignations reflects
those policies.
2. Effects of Reclassification
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 area wage index
determined inclusive of the wage data for the redesignated hospitals
(the combined wage index value) applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals
increases the wage index value for the area to which the hospitals are
redesignated, both the area and the redesignated hospitals receive the
combined wage index value.
The wage index value for a redesignated urban or rural
hospital cannot be reduced below the wage index value for the rural
areas of the State in which the hospital is located.
Rural areas whose wage index values would be reduced by
excluding the wage data for hospitals that have been redesignated to
another area continue to have their wage index values calculated as if
no redesignation had occurred.
Rural areas whose wage index values increase as a result
of excluding the wage data for the hospitals that have been
redesignated to another area have their wage index values calculated
exclusive of the wage data of the redesignated hospitals.
Currently, the wage index value for an urban area is
calculated exclusive of the wage data for hospitals that have been
reclassified to another area.
For the FY 2002 wage index, we include the wage data for a
reclassified urban hospital in both the area to which it is
reclassified and the MSA where the hospital is physically located. We
believe this improves consistency and predictability in hospital
reclassification and wage indexes, as well as alleviates the
fluctuations in the wage indexes due to reclassifications. For example,
hospitals applying to reclassify into another area will know which
hospitals' data will be included in calculating the wage index, because
even if some hospitals in the area are reclassified, their data will be
included in the calculation of the wage index of the area where they
are geographically located. Also, in some cases, excluding the data of
hospitals reclassified to another MSA could have a large downward
impact on the wage index of the MSA in which the hospital is physically
located. The negative impact of removing the data of the reclassified
hospitals from the wage index calculation could lead to large wage
disparities between the reclassified hospitals and other hospitals in
the MSA, as the remaining hospitals would receive reduced payments due
to a lower wage index. Our approach is to promote consistency and
simplify our rules with respect to how we construct the wage indexes of
rural and urban areas. As noted above, in the case of rural hospitals
redesignated to another area, the wage index of the rural area where
the hospitals are geographically located is calculated by including the
wage data of the redesignated hospitals (unless doing so would result
in a lower wage index).
Finally, we note that the Medicare Payment Advisory Commission
(MedPAC), in its March 2001 ``Report to the Congress: Medicare Payment
Policy,'' recommended this policy (p. 82). (Section VII. of this
preamble includes a discussion of MedPAC's recommendations and our
responses.) To illustrate the potential negative impact on hospitals in
an area where reclassifications of some hospitals to another area
results in a decline in the wage index after the reclassified hospitals
are excluded from the wage
[[Page 39866]]
index calculation, MedPAC points out that hospitals in several MSAs
have organized to pay qualifying hospitals not to reclassify. Our
policy change in this final rule removes this distorted incentive.
Comment: One commenter had some concerns about the reclassification
of rural hospitals. This commenter had two points. The first point was
that rural hospitals that seek reclassification to urban areas and end
up ``empty'' because all the urban hospitals have successfully sought
reclassification elsewhere continue to be disadvantaged because the
rural hospitals continue to compete with the urban hospitals in that
area, but those urban hospitals are receiving even higher payments,
while the rural hospitals are not receiving the same payments. The
commenter believed that the solution to this dilemma is to allow the
rural hospitals that seek reclassification to an ``empty'' MSA to
receive the same wage index as the urban hospitals that were able to
reclassify out of that MSA, essentially reclassifying both the urban
hospitals and the proximate rural hospitals to the same area. One other
commenter made this same point about urban hospitals.
The commenter's second point was that, periodically, based on
updated census data, new MSAs appear. Sometimes, a rural hospital
seeking reclassification to the nearest MSA or rural area is
disadvantaged when this occurs because reclassification to the new MSA
does not afford the rural hospital the same advantages as
reclassification to the MSA to which it formerly sought
reclassification, but now is not the closest MSA. The commenter wrote
that rural hospitals previously qualified for geographic
reclassification to an MSA should retain the option to reclassify to
that MSA despite the fact that a closer MSA is created.
Response: First, both rural and, for FY 2002, urban hospitals are
advantaged by the fact that we hold all areas harmless when calculating
the wage index for hospitals reclassifying into both MSAs and rural
areas. While we understand the commenter's point about its competitors,
we do not believe that this justifies a ``piggyback'' effect for
reclassification purposes wherein either rural or urban hospitals that
obtain reclassification into an empty MSA should then be reclassified
again to an area to which these hospitals are not proximate. Since a
hospital in this type of situation could not obtain reclassification on
its own to the area to which the hospitals that have vacated the MSA
have reclassified, we do not believe that it would be appropriate to
reclassify them based on the reclassification of another hospital.
Second, a hospital that is not subject to the proximity criteria
because it has a special status as either a rural referral center or a
SCH already has an advantage over other reclassifying hospitals in that
it can utilize a larger radius in seeking reclassification
opportunities (under Sec. 412.230(a)(3)). Rural referral centers and
SCHs may also reclassify to any MSA to which they qualify under
Sec. 412.230(b). We believe these criteria provide adequate opportunity
for rural referral centers and SCHs to reclassify.
Comment: Commenters generally supported our proposal to include the
wage data for a reclassified urban hospital in both the area to which
it is reclassified and the MSA where the hospital is physically
located. The commenters expressed that this would provide more
stability in the calculation of the wage index, allowing them to plan
their budgets from year-to-year with more predictability.
We did not receive any negative comments on this proposal; however,
we did receive one additional comment that encouraged us to extend the
hold harmless provision to a further degree. This commenter believed
that both rural and urban hospitals should benefit from the same hold-
harmless policy. In other words, an urban hospital's wage data should
be included in the area in which it is physically located if it
benefits the area. However, The commenter further stated that, on the
other hand, if it benefits the area to exclude that hospital's wage
data in the event the hospital successfully seeks reclassification for
the wage index to another area, then the hospital's data should be
excluded. The commenter believed that some urban areas may be harmed by
retaining the wage data of urban hospitals that are reclassifying out
of those areas.
Response: We appreciate the commenters' support of our proposal to
retain an urban hospital's wage data in the area in which it is
physically located, even if that hospital successfully seeks
reclassification to another area. As we proposed in the proposed rule,
in this final rule we are calculating the wage index for urban areas
effective for FY 2002 payments by including the wage data for a
reclassified urban hospital in both the area to which it is
reclassified and the MSA where the hospital is physically located.
In reference to the commenter who believed that we should apply the
same hold-harmless policy to urban hospitals as we do to rural
hospitals, we note that the rural hold-harmless policy (as described
above) is dictated by section 1886(d)(8)(C)(iii) of the Act. We believe
that hospitals continue to compete for services with the hospitals that
are grouped with them in their respective MSAs. Therefore, it would be
appropriate to continue to calculate the wage index for those areas as
if those hospitals had not reclassified to another area. As a result,
we intend to implement our policy to hold urban areas harmless to the
extent that the wages of the hospitals that are physically located
within urban areas will continue to be used in the compilation of the
wage index whether or not these hospitals successfully seek
reclassification elsewhere.
Comment: Several commenters expressed interest in utilizing the
occupational mix data to apply for reclassification for the wage index.
These commenters pointed out that, at one time, hospitals did have the
option to use occupational mix data to seek reclassification for the
wage index as those data were made available by the AHA. In addition to
the other applicable criteria for reclassification, a hospital that
applied for reclassification for the wage index using this criterion
was required to show that its average hourly wage, based on
occupational mix data, was 90 percent of the area to which it sought
reclassification.
Response: Prior to requests for reclassification effective during
FY 1999, a hospital could be reclassified for the wage index by showing
that its average hourly wage weighted for occupational categories was
at least 90 percent of the average hourly wage of the hospitals in the
area to which it sought reclassification (in addition to the other
applicable criteria for reclassification). Occupational mix data were
available from the AHA; however, the AHA stopped collecting the data in
1993. Therefore, because there was no other suitable source of
occupational mix data for hospitals to use, we eliminated the option
for using this data effective with reclassification requests for FY
1999 (62 FR 45988).
Section 304(c) of Public Law 106-554 requires that the Secretary
must provide for the collection of data every 3 years on the
occupational mix of employees for each short-term, acute care hospital
participating in the Medicare program, in order to construct an
occupational mix adjustment to the wage index. These data are to be
collected by September 30, 2003. Section 304(c) also requires that the
data are to be applied in the wage index by October 1, 2004. At that
point, the data will be incorporated into a hospital's average
[[Page 39867]]
hourly wages. Therefore, the occupational mix data will be reflected in
hospital reclassifications for the wage index as it is incorporated
into the wage index data. In addition, as soon as viable occupational
mix data become available, we will consider providing hospitals with
the opportunity to use it to support their reclassification requests.
The wage index values for FY 2002 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.
As mentioned earlier, section 304(a) of Public Law 106-554 amended
section 1886(d)(10)(D) of the Act by adding a new clause (v) to provide
that a reclassification of a hospital by the MGCRB for purposes of the
wage index is effective for 3 years (instead of 1 year) unless, under
procedures established by the Secretary, the hospital elects to
terminate the reclassification before the end of the 3-year period.
Section 304(a) of Public Law 106-554 also amended section
1886(d)(10)(D) of the Act to specify that, for applications for
reclassification for the wage index for FYs 2003 and later, the MGCRB
must base any comparison of the average hourly wage of the hospital
with the average hourly wage for hospitals in the area in which it is
located and the area to which it seeks reclassification, using data
from the most recently published hospital wage survey (as of the date
of the hospital's application), as well as data from each of the two
immediately preceding surveys. (Our policies in this final rule to
incorporate the provisions of section 304(a) of Public Law 106-554 in
the regulations are addressed in section IV.G. of this final rule).
Consistent with the section 304(a) amendment, Tables 3A and 3B list
the 3-year average hourly wage for each labor market area before the
redesignation of hospitals, based on FY 1996, 1997, and 1998 wage data.
Table 3A lists these data for urban areas and Table 3B lists these data
for rural areas. In addition, Table 2 in the Addendum to this final
rule includes the adjusted average hourly wage for each hospital from
the FY 1996 and FY 1997 cost reporting periods, as well as the FY 1998
period used to calculate the FY 2002 wage index. Table 2 also shows the
3-year average that the MGCRB will use to evaluate a hospital's
application for reclassification for FY 2003 (unless that average
hourly wage is later revised in accordance with Sec. 412.63(w)(2)). The
3-year averages are calculated by dividing the sum of the dollars
(adjusted to a common reporting period using the method described
previously in this section) across all 3 years, by the sum of the
hours. If a hospital is missing data for any of the previous years, its
average hourly wage for the 3-year period is calculated based on the
data available during that period.
Applications for FY 2003 reclassifications are due to the MGCRB by
September 4, 2001. (We note that, as of May 21, 2001, the new location
and mailing address of the MGCRB and the Provider Reimbursement Review
Board (PRRB) is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD
21244-2670. Also, please specify whether the mail is intended for the
MGCRB or the PRRB.)
We indicated in the proposed rule that, at the time the proposed
wage index was constructed, the MGCRB had completed its review of FY
2002 reclassification requests. The final FY 2002 wage index values
incorporate all 643 hospitals redesignated for purposes of the wage
index (hospitals redesignated under section 1886(d)(8)(B) or section
1886(d)(10) of the Act for FY 2002. Since publication of the May 4
proposed rule, the number of reclassifications has changed because some
MGCRB decisions were still under review by the Administrator and
because some hospitals decided to withdraw their requests for
reclassification.
Changes to the wage index that resulted from withdrawals of
requests for reclassification, wage index corrections, appeals, and the
Administrator's review process have been incorporated into the wage
index values published in this final rule. The changes may affect not
only the wage index value for specific geographic areas, but also the
wage index value redesignated hospitals receive; that is, whether they
receive the wage index value for the area to which they are
redesignated, or a wage index value that includes the data for both the
hospitals already in the area and the redesignated hospitals. Further,
the wage index value for the area from which the hospitals are
redesignated may be affected.
Under Sec. 412.273, hospitals that have been reclassified by the
MGCRB were permitted to withdraw their applications within 45 days of
the publication of the May 4, 2001 proposed rule. The request for
withdrawal of an application for reclassification that would be
effective in FY 2002 had to be received by the MGCRB by June 18, 2001.
A hospital that requested to withdraw its application may not later
request that the MGCRB decision be reinstated.
In addition, because the 3-year effect of the amendment made by
section 304(a) of Public Law 106-554 is applicable to reclassifications
for FY 2001 (which had already taken place prior to the date of
enactment of Public Law 106-554) and because the application process
for reclassification for FY 2002 had already been completed by the date
of enactment, we are deeming hospitals that are reclassified for
purposes of the wage index to one area for FY 2001 and are reclassified
for purposes of the wage index or the standardized amount to another
area for FY 2002 to be reclassified to the area for which they applied
for FY 2002, unless they elected to receive the wage index
reclassification they were granted for FY 2001. Consistent with our
application withdrawal procedures under Sec. 412.273, we allowed
hospitals that wished to receive, for FY 2002, the reclassification
they were granted for FY 2001, to withdraw their applications by June
18, 2001 also.
Comment: Two commenters requested us to continue publishing the
case-mix index because it assists hospitals in monitoring possible
referral center qualifying status and in preparing applications for
reclassification to use another area's standardized amount. (We also
received numerous telephone calls with this request.)
Response: Prior to this year, the case-mix index was published in
Table 3C. This index shows the average DRG relative weight for
discharges from a prior fiscal year. Due to the requirement to publish
so much additional average hourly wage data in Tables 2, 3A, and 3B, we
stopped publishing the case-mix index beginning with the May 4, 2001
proposed rule.
In light of public comments and in balancing the requirements for
additional publication of average hourly wage data, we will resume
publishing the case-mix index, but not in the Federal Register.
Beginning with the publication date of this final rule, we will make
the case-mix index for FY 2000 and future fiscal years available on
[[Page 39868]]
the internet at: http://www.hcfa.gov/medicare/ippsmain.htm. We intend
to update the case-mix index at this website to coincide with the
publication of the annual proposed and final rules.
3. Statewide Wage Index
As stated earlier, section 304(b) of Public Law 106-554 requires
the Secretary to establish, by October 1, 2001, a process (based on the
voluntary process utilized by the Secretary under section 1848 of the
Act) under which an appropriate statewide entity may apply to have all
the geographic areas in the State treated as a single geographic area
for purposes of computing and applying a single wage index, beginning
in FY 2003. Section 304(b) further requires that, if the Secretary
applies a statewide wage index to an area, an application by an
individual hospital in that area would not be considered. We believe
the reference to the voluntary process utilized by the Secretary under
section 1848 of the Act refers to the process whereby we allow a State
containing multiple physician fee schedule payment areas (and thus
multiple geographic adjustment factors) to voluntarily convert to a
single statewide payment area with a single geographic adjustment
factor (see Sec. 414.4(b), as discussed in the June 24, 1994 Federal
Register (59 FR 32759).
Section IV.G. of this final rule contains our policy for
implementing the provisions of section 304(b) in regulations. We are
providing that hospitals that seek a statewide geographic
reclassification under the amendments made by section 304(b) of Public
Law 106-554 must apply to the MGCRB with the same deadlines as other
hospitals. An approved application by the MGCRB will mean that the data
of all the hospitals in the State will be used in computing and
applying the wage index for that State. We are providing that the
statewide wage index is applicable for 3 years from the date of
approval or until all of the participating hospitals terminate their
approved statewide wage index reclassification (effective with the next
full fiscal year after their termination request), whichever occurs
first.
4. Section 402 of Public Law 106-113
Beginning October 1, 1988, section 1886(d)(8)(B) of the Act
required us to treat a hospital located in a rural county adjacent to
one or more urban areas as being located in the MSA to which the
greatest number of workers in the county commute, if the rural county
would otherwise be considered part of an urban area under the standards
published in the Federal Register on January 3, 1980 (45 FR 956) for
designating MSAs (and for designating NECMAs), and if the commuting
rates used in determining outlying counties (or, for New England,
similar recognized areas) were determined on the basis of the aggregate
number of resident workers who commute to (and, if applicable under the
standards, from) the central county or counties of all contiguous MSAs
(or NECMAs)). Hospitals that met the criteria using the January 3, 1980
version of these OMB standards were deemed urban for purposes of the
standardized amounts and for purposes of assigning the wage index.
During FY 1994, we incorporated the revised MSA definitions based
on 1990 census population data. As a result, some counties that
previously were treated as an adjacent county under section
1886(d)(8)(B) of the Act officially became part of certain MSAs.
However, as specified in the Act, we continued to utilize the January
3, 1980 standards. For FY 2000, there were 27 hospitals in 22 counties
affected by this provision.
On March 30, 1990, OMB issued revised 1990 standards (55 FR 12154).
There has been an increasing amount of interest by the hospital
industry in using the 1990 standards as opposed to the 1980 standards
to determine which hospitals qualify under the provisions set forth in
section 1886(d)(8)(B) of the Act. Section 402 of Public Law 106-113
provides that, with respect to FYs 2001 and 2002, a hospital may elect
to have the 1990 standards applied to it for purposes of section
1886(d)(8)(B) and that, beginning with FY 2003, hospitals will be
required to use the standards published in the Federal Register by the
Director of OMB based on the most recent decennial census.
We worked with staff of the Population Distribution Branch within
the Population Division of the Census Bureau to compile a list of
hospitals that meet the March 30, 1990 standards using 1990 census
population data and information prepared for the Metropolitan Area
Standards Review Project. The conditions that must be met for a
hospital located in a rural county adjacent to one or more urban areas
to be treated as being located in the urban area to which the greatest
number of workers in the rural county commute are as follows:
The rural county would otherwise be considered part of an
MSA but for the fact that the rural county does not meet the standard
established by OMB relating to the commuting rate of workers between
the county and the central county or counties of any adjacent MSA.
The county would meet the commuting standard if commuting
to (and where applicable, from) the central county or central counties
of all adjacent MSAs or NECMAs (rather than to just one) were
considered.
A county meeting the above commuting standards must also meet the
other standards established by OMB for inclusion in an MSA as an
outlying county. In order to meet these requirements, the rural county
must have a degree of ``metropolitan character.'' ``Metropolitan
character'' is established by meeting one of the following OMB
standards, which were published in the Federal Register on March 30,
1990:
a. At least 50 percent of the employed workers residing in the
county commute to the central county/counties, and either--
The population density of the county is at least 25
persons per square mile; or
At least 10 percent of the population, or at least 5,000
persons, lives in the qualifier urbanized area(s).
b. From 40 to 50 percent of the employed workers commute to the
central county/counties, and either--
The population density is at least 35 persons per square
mile; or
At least 10 percent of the population, or at least 5,000
persons, lives in the qualifier urbanized area(s).
c. From 25 to 40 percent of the employed workers commute to the
central county/counties and either the population density of the county
is at least 50 persons per square mile, or any two of the following
conditions exist:
Population density is at least 35 persons per square mile.
At least 35 percent of the population is urban.
At least 10 percent of the population, or at least 5,000
persons, lives in the qualifier urbanizer area(s).
d. From 15 to 25 percent of the employed workers commute to the
central county/counties, the population density of the county is at
least 50 persons per square mile, and any two of the following
conditions also exist:
Population density is at least 60 persons per square mile.
At least 35 percent of the population is urban.
Population growth between the last two decennial censuses
is at least 20 percent.
At least 10 percent of the population, or at least 5,000
persons, lives in the qualifier urbanized area(s).
Also accepted as meeting this commuting requirement under item d.
are:
[[Page 39869]]
The number of persons working in the county who live in
the central county/counties is equal to at least 15 percent of the
number of employed workers living in the county; or
The sum of the number of workers commuting to and from the
central county/counties is equal to at least 20 percent of the number
of employed workers living in the county.
e. From 15 to 25 percent of the employed workers commute to the
central county/counties, the population density of the county is less
than 50 persons per square mile, and any two of the following
conditions also exist:
At least 35 percent of the population is urban.
Population growth between the last two decennial censuses
is at least 20 percent.
At least 10 percent of the population, or at least 5,000
persons, lives in the qualifier urbanized area(s).
f. At least 2,500 of the population lives in a central city of the
MSA located in the qualifier urbanized area(s).
When we apply the 1990 standards as opposed to 1980 standards, the
number of qualifying counties increases from 22 to 31. On the basis of
the evaluation of these data, effective for discharges occurring on or
after October 1, 2001, hospitals listed in the first column of the
following table are considered, for purposes of assigning the inpatient
standardized amount and the wage index, to be located in the
corresponding urban area in the second column:
----------------------------------------------------------------------------------------------------------------
Rural county MSA
----------------------------------------------------------------------------------------------------------------
Chilton, AL................................ Birmingham, AL
Marshall, AL............................... Huntsville, AL
Talladega, AL.............................. Anniston, AL
Bradford, FL............................... Jacksonville, FL
Hendry, FL................................. West Palm Beach-Boca Raton, FL
Putnam, FL................................. Gainesville, FL
Jackson, GA................................ Athens, GA
Christian, IL.............................. Springfield, IL
Macoupin, IL............................... St. Louis, MO-IL
Piatt, IL.................................. Champaign-Urbana, IL
Brown, IN.................................. Indianapolis, IN
Carroll, IN................................ Lafayette, IN
Henry, IN.................................. Indianapolis, IN
Jefferson, KS.............................. Topeka, KS
Barry, MI.................................. Kalamazoo-Battle Creek, MI
Cass, MI................................... Benton Harbor, MI
Ionia, MI.................................. Grand Rapids-Muskegon-Holland, MI
Shiawassee, MI............................. Flint, MI
Tuscola, MI................................ Saginaw-Bay City-Midland, MI
Caswell, NC................................ Greensboro-Winston Salem-High Point, NC
Greene, NC................................. Greenville, NC
Harnett, NC................................ Raleigh-Durham-Chapel Hill, NC
Wilson, NC................................. Rocky Mount, NC
Preble, OH................................. Dayton-Springfield, OH
Van Wert, OH............................... Lima, OH
Adams, PA.................................. York, PA
Lawrence, PA............................... Pittsburgh, PA
Monroe, PA................................. Newark, NJ
Schuylkill, PA............................. Reading, PA
Jefferson, WI.............................. Milwaukee-Waukesha, WI
Walworth, WI............................... Milwaukee-Waukesha, WI
----------------------------------------------------------------------------------------------------------------
There are 14 counties that meet the qualifying criteria using 1990
standards that did not meet the criteria using the 1980 standards.
These 14 counties are:
Chilton, AL
Talladega, AL
Bradford, FL
Hendry, FL
Putnam, FL
Jackson, GA
Piatt, IL
Brown, IN
Carroll, IN
Greene, NC
Wilson, NC
Adams, PA
Monroe, PA
Schuylkill, PA.
In addition, when we apply the 1980 standards for three of the
counties, the MSA assigned is different from the MSA that would be
assigned using the 1990 standards. These counties are as follows:
----------------------------------------------------------------------------------------------------------------
1980 MSA
Rural county designation 1990 MSA designation
----------------------------------------------------------------------------------------------------------------
Ionia, MI....................... Lansing-East Grand Rapids-Muskegon-Holland, MI.
Lansing, MI.
Caswell, NC..................... Danville, VA....... Greensboro-Winston Salem-High Point, NC.
Harnett, NC..................... Fayetteville, NC... Raleigh-Durham-Chapel Hill, NC.
----------------------------------------------------------------------------------------------------------------
Section 402 of Public Law 106-113 states that hospitals may elect
to use either the January 3, 1980 standards or the March 30, 1990
standards for payments during FY 2001 and FY 2002. We are assuming
hospitals will elect to go to the MSA resulting in the highest payment
amount accounting for the applicable wage indexes and standardized
amounts. Based on our analysis, we believe all hospitals in the
designated rural counties would benefit by being included in the
respective MSAs shown above. Therefore, we proposed to assign the FY
2002
[[Page 39870]]
standardized amount and wage index of each respective MSA to the
affected hospitals. Hospitals electing not to use the 1990 standards
would be required to notify their fiscal intermediary in writing of
such election prior to September 1, 2001, in order to allow sufficient
time to reflect this change in our payment systems.
We note that five rural counties no longer meet the qualifying
criteria when we apply the revised OMB standards. These rural counties
are as follows: Indian River, FL; Mason, IL; Owen, IN; Morrow, OH; and
Lincoln, WV. For FY 2002, we continue to treat these hospitals as
attached to an MSA on the basis of the 1980 standards. Beginning FY
2003, they must meet the 1990 standards to continue to be treated as
such.
We stated in the August 1, 2000 final rule that implemented changes
to the prospective payment system for FY 2001 that we were in the
process of working with OMB to identify the hospitals that would be
affected by section 402 of Public Law 106-113 (65 FR 47076). We further
indicated we would revise payments to hospitals in the affected
counties as soon as data were available. Now that the affected counties
have been identified, hospitals in the 14 counties identified above
will be offered the opportunity to elect this designation, as
previously described. We will provide further information related to
this election, including recalculated wage indexes, through a
forthcoming program memorandum.
Finally, three hospitals located in counties affected by the
revised OMB standards also have been reclassified by the MGCRB. The
affected hospitals are listed below. If the hospitals did not wish to
be reclassified for FY 2002 based on their new designation as described
above, they had to follow the procedures described above for requesting
that their application for reclassification be withdrawn.
------------------------------------------------------------------------
FY 2002
Provider No. 1990 MSA Designation reclassification,
MSA
------------------------------------------------------------------------
34-0071..................... Raleigh-Durham- Fayetteville, NC.
Chapel Hill, NC.
34-0124..................... Raleigh-Durham- Fayetteville, NC.
Chapel Hill, NC.
34-0126..................... Rocky Mount, NC..... Raleigh-Durham-
Chapel Hill, NC
(wage index only).
------------------------------------------------------------------------
5. Provisions of the August 1, 2000 Interim Final Rule: Sections
152(a), 153, and 154a) of Public Law 106-113
In the August 1, 2000 interim final rule with comment period, we
implemented sections 152(a), 153, and 154(a) of Public Law 106-113.
These sections contained provisions under which hospitals in certain
counties are deemed to be located in specified areas for purposes of
payment under the hospital inpatient prospective payment system, for
discharges occurring during FY 2000. For payment purposes, hospitals
under section 152(a) are to be treated as though they were reclassified
for purposes of both the standardized amount and the wage index.
Sections 153 and 154(a) did not affect the standardized amount. In the
interim final rule, we calculated FY 2000 wage indexes for hospitals in
the affected counties. These wage indexes are listed below. No other
hospitals' FY 2000 wage indexes were affected, including those
hospitals in the areas to which these affected hospitals were
reclassified, as well as nonreclassified hospitals located in the areas
from which these hospitals were reclassified.
We also implemented section 152(a), which provided that, for
purposes of making payments under section 1886(d) of the Act for FY
2000--
To hospitals in Iredell County, North Carolina, Iredell
County was deemed to be located in the Charlotte-Gastonia-Rock Hill,
North Carolina-South Carolina MSA;
To hospitals in Orange County, New York, Orange County was
deemed to be located in the New York, New York MSA;
To hospitals in Lake County, Indiana and Lee County,
Illinois, Lake County and Lee County were deemed to be located in the
Chicago, Illinois MSA;
To hospitals in Hamilton-Middletown, Ohio, Hamilton-
Middletown was deemed to be located in the Cincinnati, Ohio-Kentucky-
Indiana MSA;
To hospitals in Brazoria County, Texas, Brazoria County
was deemed to be located in the Houston, Texas MSA;
To hospitals in Chittenden County, Vermont, Chittenden
County was deemed to be located in the Boston-Worcester-Lawrence-
Lowell-Brockton, Massachusetts-New Hampshire MSA.
In accordance with section 153 of Public Law 106-113, for
discharges occurring during FY 2000, the Hattiesburg, Mississippi MSA
wage index was recalculated by including the wage data for Wesley
Medical Center. In accordance with section 154(a), the Allentown-
Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was recalculated
by including the wage data for Lehigh Valley Hospital.
The following table shows the changes to the FY 2000 wage index
values for the hospitals in the affected counties. Hospitals affected
by section 152(a) of Public Law 106-113 were also considered
reclassified for purposes of the standardized amount.
----------------------------------------------------------------------------------------------------------------
New MSA (for
wage index and New Georgraphic
County or MSA standardized New wage index Adjustment
amount) Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Iredell County, NC........................................... 1520 0.9434 0.9609
Orange County, NY............................................ 5600 1.4342 1.2801
Lake County, IN.............................................. 1600 1.0750 1.0508
Lee County, IL............................................... 1600 1.0750 1.0508
Hamilton-Middletown, OH...................................... 1640 0.9419 0.9598
Brazoria County, TX.......................................... 3360 0.9388 0.9577
Chittenden County, VT........................................ 1123 1.1359 1.0912
Hattiesburg, MS MSA.......................................... 3285 0.7634 0.8312
Allentown-Bethlehem-Easton, PA MSA........................... 0240 1.0228 1.0156
----------------------------------------------------------------------------------------------------------------
[[Page 39871]]
G. Requests for Wage Data Corrections
In the May 4, 2000 proposed rule, we stated that, to allow
hospitals time to construct the proposed FY 2002 hospital wage index,
we would make available in May 2001 a final public data file containing
the FY 1998 hospital wage data.
The final wage data file was released on May 4, 2001. As noted
above in section III.D. of this preamble, this file included hospitals'
cost report data obtained from Worksheet S-3, Parts II and III of their
FY 1998 Medicare cost reports. In addition, Table 2 in the Addendum to
this final rule contains each hospital's adjusted average hourly wage
used to construct the wage index values for the past 3 years, including
the FY 1998 data used to construct the final FY 2002 wage index.
Under revised procedures, hospitals were given an opportunity to
correct any incorrectly reported FY 1998 wage data on their cost
reports and submit complete detailed supporting documentation to their
intermediaries by March 9, 2001. Wage data corrections had to be
reviewed and verified by the intermediary and transmitted to HCFA on or
before April 9, 2001. These deadlines were necessary to allow
sufficient time to review and process the data so that the final wage
index calculation could be completed for development of the final
prospective payment rates in this final rule.
We created the process described above to resolve all substantive
wage data correction disputes before we finalize the wage data for the
FY 2002 payment rates. Accordingly, hospitals that did not meet the
procedural deadlines set forth above were not afforded a later
opportunity to submit wage data corrections or to dispute the
intermediary's decision with respect to requested changes.
Specifically, our policy is that hospitals that do not meet the
procedural deadlines set forth above will not be permitted to later
challenge, before the Provider Reimbursement Review Board, HCFA's
failure to make a requested data revision (See W. A. Foote Memorial
Hospital v. Shalala, No. 99-CV-75202-DT (E.D. Mich. 2001)).
As stated above, the final wage data public use file was released
on May 4, 2001. Hospitals had an opportunity to examine both Table 2 of
the proposed rule and the May 4 final public use wage data file (which
reflected revisions to the data used to calculate the values in Table
2) to verify the data HCFA was using to calculate the wage index.
Hospitals had until June 4, 2001, to submit requests to correct errors
in the final wage data due to data entry or tabulation errors by the
intermediary or HCFA. The correction requests considered at that time
were limited to errors in the entry or tabulation of the final wage
data that the hospital could not have known about before the release of
the final wage data public use file.
If, after reviewing the May 2001 final data file, a hospital
believed that its wage data are incorrect due to a fiscal intermediary
or HCFA error in the entry or tabulation of the final wage data, it 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 4, 2001.
Changes to the hospital wage data were made in those very limited
situations involving an error by the intermediary or HCFA that the
hospital could not have known about before its review of the final wage
data file. Specifically, neither the intermediary nor HCFA accepted the
following types of requests at that stage of the process:
Requests for wage data corrections that were submitted too
late to be included in the data transmitted to HCFA on or before April
9, 2001.
Requests for correction of errors that were not, but could
have been, identified during the hospital's review of the February 2001
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 4, 2001) are incorporated into the final wage index in this final
rule, to be effective October 1, 2001.
Again, we believe the wage data correction process described above
provides hospitals with sufficient opportunity to bring errors in their
wage data to the intermediary's attention. Moreover, because hospitals
had access to the final wage data by early May 2001, 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
2002 wage index and its implementation on October 1, 2001. If hospitals
availed themselves of this opportunity, the wage index implemented on
October 1 should be accurate. Nevertheless, in the event that errors
are identified 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 2002 (that is, by the
June 4, 2001 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 necessary. 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.
H. Modification of the Process and Timetable for Updating the Wage
Index
Although the wage data correction process described above has
proven successful in the past for ensuring that the wage data used each
year to calculate the wage indexes are generally reliable and accurate,
we are concerned about the growing volume of wage data revisions
initiated by hospitals during February and the first week of March. We
first discussed this issue in the FY 1998 proposed rule (62 FR 29918).
At that time, we noted that, in developing the FY 1997 wage index, the
wage data were revised between the proposed and final rules for more
than 13 percent of the hospitals (approximately 700 of 5,200). Last
year, in developing the FY 2001 wage index, the wage data were revised
between the proposed and final rules for more than 32 percent of the
hospitals (1,605 of 4,950). This year, in developing the FY 2002 wage
index, the wage data were revised between the proposed rule and the
final rule for 30 percent of the hospitals (1,473 of 4,910).
In the May 4, 2001 proposed rule, we indicated that since hospitals
are expected to submit complete and accurate cost report data, and
intermediaries review and request hospitals to correct problematic wage
data before the data are submitted to HCFA in mid-November, we believed
there should be limited revisions at this stage of the process. We
reminded the hospital community that the primary purpose of this file
is to allow hospitals to verify that we have their correct data on
file. However, according to information received from the
intermediaries, these late revisions are frequently due to hospitals'
lack of responsiveness in providing sufficient information to the
intermediaries during the desk reviews (that is, during the
[[Page 39872]]
intermediary's review of the hospital's cost report).
In the proposed rule, we proposed two changes to the wage index
development process and timetable beginning with the FY 2003 wage
index. We believed these changes would encourage earlier submissions of
wage data revisions by hospitals and would allow intermediaries more
time to address the heavy volume of revisions requested after the
intermediaries have completed their desk reviews of these data. First,
we proposed to release the preliminary wage data file by early January
rather than early February. As with the current preliminary file, the
January file would include desk reviewed wage data that intermediaries
submitted to us by November of the previous year and any timely
revisions we received from intermediaries prior to release of the
January file. Hospitals would be allowed until early February to submit
requests for wage data revisions to their intermediaries. Second,
intermediaries would be allowed approximately 8 weeks from the
hospitals' deadline for submitting revision requests (that is, until
early March) to review and transmit revised wage data to us.
We believed that the proposed revised schedule would improve the
quality of the wage index by allowing intermediaries more time to
sufficiently review wage data revisions before the data are submitted
to us. Further, we believed the proposed revised process would
encourage hospitals to submit revisions earlier, so the proposed wage
index, from which hospitals base geographic reclassification decisions,
is more accurate.
The timetable for developing the annual update to the wage index is
as follows (an asterisk indicates no change from prior years):
Mid-November *
All desk reviews for hospitals wage data are completed and revised
data transmitted by the fiscal intermediaries to HCRIS.
Early December *
CMS compiles file of wage data, received by mid-November, and sends
it to the fiscal intermediaries for verification.
Early January
Edited wage data are available for release to the public.
Early February
Deadline for hospitals to request wage data revisions and provide
adequate documentation to support the request.
April/May *
Proposed rule published with 60-day comment period and 45-day
withdrawal deadline for hospitals applying for geographic
reclassification.
Early April *
Deadline for the fiscal intermediaries to submit all revisions
resulting from the hospitals' requests for adjustments (as of early
February) (and verification of data submitted as of early January).
Deadline for hospital's to request CMS's intervention in cases
where the hospital disagrees with the fiscal intermediary's policy
interpretations pertaining to the allowability of particular costs.
Late April *
Fiscal intermediaries will alert hospitals to the availability of
the final wage data file for their review and inform hospitals of the
June deadline for hospitals to submit correction requests for
corrections to errors due to CMS or fiscal intermediary mishandling of
the final wage data.
Early May *
Release of final wage data public use file on CMS web page and
through public use files office.
Early June *
Deadline for hospitals to submit correction requests to both CMS
and the fiscal intermediaries to correct errors due to CMS or fiscal
intermediary mishandling of the final wage data.
August 1 *
Publication of the final rule.
October 1 *
Effective date of updated wage index.
Comment: One commenter agreed, in general, with the premise of the
proposed revised schedule. The commenter recommended that we publish
the preliminary wage data file in August, using data from the
hospitals' as-filed cost reports before fiscal intermediaries begin the
wage index desk reviews. Hospitals would then have until October 1 to
submit requests, along with supporting documentation, to correct
errors. The commenter's proposal would give fiscal intermediaries until
November 30 to complete the desk review and transmit the wage index
data to us. The commenter believed that implementation of the
recommended schedule eliminates the fiscal intermediary's duplication
of effort (that is, reviewing the data a second time when hospitals
request changes after the desk review, and then resubmitting the data
to us) that exists in the current process.
Response: We appreciate the commenter's general support for our
proposal to revise the wage index schedule, and we will give the
commenter's recommended process careful consideration in developing
future updates to the wage index. Having received no other comments
opposing our proposed schedule, we will implement that schedule,
beginning with the FY 2003 wage index. We believe that our revised
schedule is a logical step in the evolution of the wage index
development process. We will monitor the effectiveness of the revised
schedule.
IV. Other Decisions and Changes to the Prospective Payment System
for Inpatient Operating Costs and Graduate Medical Education Costs
A. Sole Community Hospitals (SCHs) (Secs. 412.63, 412.71, 412.72,
412.73, 412.75, 412.77, and 412.92)
For the benefit of the reader, in this final rule, we are
discussing and clarifying many of the rules and policies governing SCHs
because of the legislative changes that have occurred in recent years.
It has been several years since the SCH criteria have been published in
one location. Rather than continue to refer to various Federal Register
documents and sections of the Code of Federal Regulations, we are
publishing a detailed discussion of these policies, making further
changes to incorporate the provisions of sections 213, 302, 303, 304,
and 311 of Public Law 106-554, and clarifying other related policies.
Under the hospital inpatient prospective payment system, special
payment protections are provided to an SCH. Section 1886(d)(5)(D)(iii)
of the Act defines an SCH as a hospital that, by reason of factors such
as isolated location, weather conditions, travel conditions, absence of
other like hospitals (as determined by the Secretary), or historical
designation by the Secretary as an Essential Access Community Hospital
(EACH), is the sole source of inpatient hospital services reasonably
available to Medicare beneficiaries. The regulations that set forth the
criteria that a hospital must meet to be classified as an SCH are at
Sec. 412.92. To be classified as an SCH, a hospital must either have
been designated as an SCH prior to the beginning of the prospective
payment system on October 1, 1983, and must be located more than 35
miles from other like hospitals, or the hospital must be
[[Page 39873]]
located in a rural area and meet one of the following requirements:
It is located more than 35 miles from other like
hospitals.
It is located between 25 and 35 miles from other like
hospitals, and it--
--Serves at least 75 percent of all inpatients, or 75 percent of
Medicare beneficiary inpatients, within a 35-mile radius or, if larger,
within its service area; or
--Has fewer than 50 beds and would qualify on the basis of serving 75
percent of its area s inpatients except that some patients seek
specialized care unavailable at the hospital.
It is located between 15 and 25 miles from other like
hospitals, and because of local topography or extreme weather
conditions, the other like hospitals are inaccessible for at least 30
days in each of 2 out of 3 years.
The travel time between the hospital and the nearest like
hospital is at least 45 minutes because of distance, posted speed
limits, and predictable weather conditions.
Effective with hospital cost reporting periods beginning on or
after April 1, 1990, section 1886(d)(5)(D)(i) of the Act, as amended by
section 6003(e) of Public Law 101-239, provides that SCHs are paid
based on whichever of the following rates yields the greatest aggregate
payment:
The Federal rate applicable to the hospital.
The updated hospital-specific rate based on FY 1982 costs
per discharge.
The updated hospital-specific rate based on FY 1987 costs
per discharge.
Effective with hospital cost reporting periods beginning on or
after October 1, 2000, section 1886(b)(3)(I)(i) of the Act, as added by
section 405 of Public Law 106-113 and amended by section 213 of Public
Law 106-554, provides for other options, in addition to the three
bulleted options in the above paragraph, for determining which rate
would yield the greatest aggregate payment. For discharges for FY 2001
through FY 2003, these additional optional rates are--
A phase-in blended rate of the updated hospital-specific
rate based on FY 1982 costs per discharge and an FY 1996 hospital-
specific rate; or
A phase-in blended rate of the updated hospital-specific
rate based on FY 1987 costs per discharge and an FY 1996 hospital-
specific rate.
For discharges beginning in FY 2004, the additional optional rate
would be 100 percent of the FY 1996 hospital-specific rate.
For each cost reporting period, the fiscal intermediary determines
which of the payment options will yield the highest rate of payment.
Payments are automatically made at the highest rate using the best data
available at the time the fiscal intermediary makes the determination.
However, it may not be possible for the fiscal intermediary to
determine in advance precisely which of the rates will yield the
highest payment by year's end. In many instances, it is not possible to
forecast the outlier payments, the amount of the DSH adjustment, or the
IME adjustment, all of which are applicable only to payments based on
the Federal rate. The fiscal intermediary makes a final adjustment at
the close of the cost reporting period to determine precisely which of
the payment rates would yield the highest payment to the hospital.
If a hospital disagrees with the fiscal intermediary's
determination regarding the final amount of program payment to which it
is entitled, it has the right to appeal the fiscal intermediary's
decision in accordance with the procedures set forth in Subpart R of
Part 405, which concern provider payment determinations and appeals.
In calculating a hospital-specific rate for an SCH based on its FY
1996 cost reporting period, we will, to the extent possible, use the
same methodology that we used to calculate the hospital-specific rate
based on either the FY 1982 or FY 1987 cost reporting period. That
methodology is set forth in Secs. 412.71, 412.72, 412.73, 412.75 and
412.77.
If a hospital has a cost reporting period ending in FY
1982, it will be paid a hospital-specific rate based on its FY 1982
costs; or a hospital-specific rate based on its FY 1987 costs; or a
hospital-specific rate based on its FY 1996 costs (which, until FY
2004, would be a blend of the greater of the FY 1982 or FY 1987 costs
and the FY 1996 costs); or it will be paid based on the Federal rate.
If a hospital has no cost reporting period ending in FY
1982, it will be paid a hospital-specific rate based on its FY 1987
costs; or a hospital-specific rate based on its FY 1996 costs (which,
until FY 2004, would be a blend of its FY 1987 costs and FY 1996
costs); or it will be paid based on the Federal rate.
If a hospital has no cost reporting period ending in
either FY 1982 or FY 1987, it will be paid based on its FY 1996 costs;
or it will be paid based on the Federal rate.
If a hospital has no cost reporting period ending in FY
1982, FY 1987, or FY 1996, it cannot be paid based on a hospital-
specific rate; it will be paid based on the Federal rate.
If a hospital was operating during any or all of FY 1982,
FY 1987, or FY 1996, but, for some reason, the cost report records are
no longer available, the hospital will be treated as if it had no cost
report for the applicable period. Section 1886(b)(3)(C) of the Act
specifies the available periods that may be used.
For each SCH, the fiscal intermediary will calculate a hospital-
specific rate based on the hospital's FY 1982, FY 1987, or FY 1996 cost
report as follows:
Determine the hospital's total allowable Medicare
inpatient operating cost, as stated on the cost report.
Divide the total Medicare operating cost by the number of
Medicare discharges (without adjusting for transfers) in the cost
reporting period to determine the base period cost per case.
In order to take into consideration the hospital's
individual case-mix, the base year cost per case is divided by the
hospital's case-mix index applicable to the cost reporting period. This
step is necessary to adjust the hospital's base period cost for case
mix. This is done to remove the effects of case mix from the base
period costs per case. Payments using these base period costs are then
adjusted to reflect the actual case mix during the payment year. A
hospital's case mix is computed based on its Medicare patient
discharges subject to DRG-based payment.
The fiscal intermediary will inform each SCH of its hospital-
specific rate based on its applicable cost reporting period within 180
days after the start of its cost reporting period.
(The provisions of section 213 of Public Law 106-554 relating to
the extension to all SCHs the option to rebase using their FY 1996
operating costs, for cost reporting periods beginning on or after
October 1, 2000, were addressed in the June 13, 2001 interim final rule
with comment period, and are finalized in this final rule.)
An SCH is also eligible for a payment adjustment if, for reasons
beyond its control, it experiences a decline in volume of greater than
5 percent compared to its preceding cost reporting period. This
adjustment is also available to hospitals that could qualify as SCHs
but choose not to be paid as SCHs; that is, hospitals that qualify and
successfully apply to be designated as SCHs but continue to receive
payments based on the Federal rate. In addition, section 6003(c)(1) of
Public Law 101-239 deleted the sunset date on the 5-percent volume
decline adjustment, thus allowing SCHs to receive the adjustment
indefinitely. The sunset provision was included under section
1886(d)(5)(C)(ii) of the Act. (Section 6003(c)(1) of Public Law 101-239
amended that provision and
[[Page 39874]]
redesignated it as section 1886(d)(5)(D) of the Act.)
In the September 1, 1983, issue of the Federal Register (48 FR
39781), we stated that any hospital designated as an SCH would retain
that status until it experienced a change in circumstances. Section
6003(e)(3) of Public Law 101-239 specifically stated that any hospital
classified as an SCH as of the date of enactment of Public Law 101-239
(December 19, 1989), will retain its SCH status even if the hospital
did not meet the criteria established under section 6003(e)(1) of that
law. These hospitals are the ``grandfathered'' SCH hospitals.
Therefore, we have continued to allow hospitals designated as SCHs
prior to December 19, 1989, to be ``grandfathered'' under current
criteria.
In the June 4, 1991 Federal Register, we stated that a hospital's
special status as an SCH would not be retained in light of the
hospital's geographic reclassification for purposes of the standardized
amount. In the event the hospital's reclassification ceases, it must
reapply for special status and must meet all of the applicable
qualifying criteria in effect at the time it seeks requalification (56
FR 25482). However, in the event a ``grandfathered'' SCH was
successfully reclassified, it would be reinstated as an SCH if its
reclassification ceased.
Section 401(a) of Public Law 106-113 established that any
subsection (d) hospital (section 1886(d) of the Act) located in an
urban area may be redesignated as being located in a rural area if the
hospital meets one of several criteria established by the legislation.
One of these criteria is that the hospital could qualify as an SCH if
the hospital were located in a rural area. Under this provision, an
urban hospital that may have been ``grandfathered'' as an SCH could now
qualify and receive payment as an SCH if it met the criteria of a rural
SCH instead of as an urban SCH. Given this extension of SCH
eligibility, we no longer believe it is necessary to extend special
protection to ``grandfathered'' SCHs that successfully apply for
geographic reclassification through the MGCRB for the standardized
amount after their MGCRB reclassification ends. Therefore, a hospital
that loses its SCH status through a change in circumstances, such as
reclassification through the MGCRB for the standardized amount, will
not be reinstated as a SCH unless it can meet all of the SCH qualifying
criteria in effect at the time it seeks requalification. This
circumstance falls under the provisions of Secs. 412.92 (b)(3) and
(b)(5), which state that an approved classification as an SCH remains
in effect without need for reapproval unless there is a change in the
circumstances under which the classification was approved. We believe
that a successful reclassification by the MGCRB fits the definition of
a change in circumstances.
Because some hospitals may not have understood the effect
reclassification would have on their special status, in the May 4
proposed rule we permitted affected hospitals, under existing
Sec. 412.273(a), the option to withdraw their applications for
reclassification for FY 2002, even if the MGCRB had issued a decision,
by submitting a withdrawal request to the MGCRB within 45 days of
publication of this proposed rule. Finally, just as a competing
hospital that closes leaves an opportunity for an existing hospital to
qualify as an SCH, a new hospital that opens in an area with an
existing hospital designated as an SCH endangers the SCH status of the
existing hospital.
As of October 1, 1997, no designations of hospitals as EACHs can be
made. The EACHs designated by CMS before October 1, 1997, will continue
to be paid as SCHs for as long as they comply with the terms,
conditions, and limitations under which they were designated as EACHs.
Under Sec. 412.92(b)(2), we define the effective dates for several
situations in which a hospital gains or gives up SCH status. First, SCH
status and the associated payment adjustment is effective 30 days after
CMS's written notification to the SCH. Thus, 30 days after the issuance
of CMS's notice of approval, the hospital is considered to be an SCH
and the payment adjustment is applied to discharges occurring on or
after that date.
Second, Sec. 412.92(b)(4)(ii) defines the effective date when a
hospital chooses to give up its SCH status. Our policy has always been
that an SCH can elect to give up its SCH status at any time by
submitting a written request to the appropriate CMS regional office
through its fiscal intermediary. The change to fully national rates
becomes effective no later than 30 days after the hospital submits its
request. We believe that the ``no later than 30 days'' policy for the
effective date for cancelling SCH status is in keeping with the
prospective nature of the prospective payment system. In addition, the
30-day timeframe to give up SCH status provides the fiscal
intermediaries with enough time to alter their automated payment
systems prospectively, thus avoiding expensive and time-consuming
reprocessing of claims. The variable timeframe of ``no later than 30
days from the date of the hospital's request'' also permits the
regional office, the fiscal intermediary, and the hospital to select a
mutually agreeable date, for example, at the end of a month, to
facilitate the change in SCH status. We expect that hospitals will
anticipate when they wish to give up SCH status and to submit their
requests in sufficient time to permit the 30-day period for making the
change.
In addition, Sec. 412.92(b)(2)(ii) defines the effective date of
SCH status in the situation where a final and nonappealable
administrative or judicial decision reverses CMS's denial of SCH status
to a hospital. In this situation, if the hospital's application was
submitted on or after October 1, 1983, the effective date will be 30
days after the date of CMS's original written notification of denial.
Under Sec. 412.92(b)(2)(iii), we define retroactive approval of SCH
status. If a hospital is granted retroactive approval of SCH status by
a final and nonappealable court order or an administrative decision
under subpart R of part 405 of the regulations, and it wishes its SCH
status terminated prior to the current date (that is, it wishes to be
paid as an SCH for a time-limited period, all of which is in the past),
it must submit written notice to the CMS regional office through its
fiscal intermediary within 90 days of the court order or the
administrative decision. This written notice must clearly state that,
although SCH status was granted retroactively by the court order or by
the administrative decision, the hospital wants this status terminated
as of a specific date. If written notice is not received within 90 days
of the court order or the administrative decision, SCH status will
continue. Written requests to terminate SCH status that are received
subsequent to the 90-day period will be effective no later than 30 days
after the request is submitted, as discussed above.
Under Sec. 412.92(c)(1), we define mileage. We believe that mileage
should continue to be measured by the shortest route over improved
roads maintained by any local, State, or Federal government entity for
public use. We consider improved roads to include the paved surface up
to the front entrance of the hospital because this portion of the
distance is utilized by the public to access the hospital. This
definition provides consistency with the interpretation of the MGCRB
when considering hospital reclassification applications. The MGCRB
measures the distance between the hospital and the county line of the
area to which it seeks reclassification beginning with the paved area
outside the front entrance of
[[Page 39875]]
the hospital. This provides a consistent, national definition that is
easily recognizable for each hospital. Finally, rounding of mileage is
not permissible. This is also consistent with the MGCRB definition of
mileage (56 FR 25483). In this final rule, we are revising the
definition of ``miles'' under Sec. 412.92(c)(1) to state that an
improved road includes the paved surface up to the front entrance of
the hospital.
Under Sec. 412.92(c)(2), we define ``like'' hospital. We consider
like hospitals to be those hospitals furnishing short-term acute care.
That is, a hospital may not qualify for an SCH classification on the
grounds that neighboring hospitals offer specialty services, thereby
seeking to exclude close-by competitors as like hospitals, in order to
meet the mileage criteria by measuring to a like hospital that is
located further away. For example, we believe that competing hospitals
within a given area may each have their own specialty services, while
all the facilities continue to be considered short-term acute care
hospitals. We note that under Sec. 412.92(a)(1)(ii), a hospital with
fewer than 50 beds may qualify for SCH status under a special provision
if patients that it would normally serve are seeking care elsewhere due
to the unavailability of specialty services. This means that, if a
hospital can prove that the patients from its service area are seeking
specialty services elsewhere (such as, among others, heart surgery,
transplants, and burn care), rather than routine care, and, because of
that fact, that it otherwise would have met the criteria of section
Sec. 412.92(a)(1)(i), it can qualify as an SCH.
We note that Sec. 412.92(b)(1)(iii)(A) retains an outdated
reference to ``hospitals located within a 50 mile radius of the
hospital.'' With the issuance of the September 1, 1989 Federal Register
(54 FR 36481, 36482), the 50 mile radius was determined to be
unreasonable and all references should have been changed to 35 miles in
accordance with Sec. 412.92(a)(1)(i). In this final rule. we are
revising the reference to ``a 50 mile radius'' in
Sec. 412.92(b)(1)(iii)(A) to read ``a 35 mile radius''.
We note that the travel time and weather conditions criteria set
forth in Sec. 412.92(a)(3) were discussed in detail in the September 4,
1990 Federal Register (55 FR 36050 through 36055 and 36162 through
36163).
Under Sec. 412.92(a)(1)(i) and (b)(1)(ii), we define the market
area analysis criteria used to determine SCH status. In the May 4, 2001
proposed rule, we discussed several points concerning these requests
for SCH status that we proposed to clarify.
First, a hospital seeking an SCH designation based on these
criteria must make its initial request to the fiscal intermediary with
all the appropriate documents as will be discussed below
(Sec. 412.92(b)(1)(i)). The fiscal intermediary will make a
recommendation on the request, based on receipt of all the appropriate
documentation and its own investigation and analysis, and that
recommendation will be forwarded to the CMS regional office for another
level of review and final approval or disapproval. The fiscal
intermediary would forward its recommendation to the CMS regional
office located in the hospital's area as opposed to the fiscal
intermediary's area, if there is a difference in these areas. As
discussed above, an approval of the request for SCH status will be
effective 30 days after CMS issues the approval letter. If a
determination on the request requires the use of data that are
available at CMS central office only, upon receipt of the fiscal
intermediary's recommendation, the CMS regional office will forward the
request and the fiscal intermediary's recommendation to the appropriate
contact at CMS central office where the determination will be made.
Second, a hospital must provide patient origin data (the number of
patients from each zip code from which the hospital draws inpatients)
for all inpatient discharges to document the boundaries of its service
area (Sec. 412.92(b)(1)(ii)(A)). Or, the hospital can request that CMS
develop patient origin data to define its service area based on the
number of patients from each zip code from which the hospital draws
Medicare Part A inpatients (Sec. 412.92(b)(1)(iii)). Then, the lowest
number of zip codes in descending percentage order of Medicare
inpatients that meets the 75-percent threshold will be used to
represent the hospital's service area. We note that hospitals cannot
substitute zip codes elsewhere on the list in order to manipulate the
service area. (See Howard Young Medical Center, Inc. v. Shalala, 207
F.3d 437 (7th Cir. 2000).)
Third, the hospital must provide patient origin data from all other
hospitals located within a 35-mile radius of it or, if larger, within
its service area, to document that no more than 25 percent of either
all of the population or the Medicare beneficiaries residing in the
hospital's service area and hospitalized for inpatient care were
admitted to other like hospitals for care (Sec. 412.92(b)(1)(ii)(B)).
Again, CMS central office can develop patient origin data for other
hospitals within the requesting hospital's service area if the hospital
is requesting SCH status based on an examination of Medicare Part A
inpatient utilization. In either case, the requesting hospital is
required to submit a comprehensive list of hospitals located within a
35-mile radius or, if larger, within its service area. This list will
be checked by both the fiscal intermediary and CMS. Again, a requesting
hospital cannot argue that a competing hospital should be excluded from
the service area based on the existence of specialty services at that
hospital if both hospitals are short-term acute care facilities.
Distances between all reported hospitals will be checked by both the
fiscal intermediary and CMS, through electronic geographic mapping
services (such as Yahoo or Mapquest) or by physically driving the
distance involved.
In addition, data will be analyzed based on the year for which the
hospital requests SCH status. Subsequent hospital mergers or
terminations will not be taken into consideration in processing the
request. For example, if a hospital requests SCH status using data for
FY 1999, and that data show that there is a competing hospital in
existence that subsequently closed its doors in FY 2000, the data will
be analyzed with the terminated hospital in existence, unless the
hospital seeking SCH status applies using later data, such as FY 2001.
This principle is consistent with how we analyze wage index data. If a
terminated hospital has a viable cost report for the year of wage data
that is being analyzed to produce the wage index, its data are included
as part of the computation.
We received the following comments on our May 4, 2001 proposed rule
and the June 13, 2001 interim final rule with comment period:
Comment: Several commenters were concerned with the following
issues related to the qualifying criteria for sole community hospitals:
(1) Utilizing TAC worksheets or other data sources in order to develop
a base year alternative for a new SCH; (2) determining a service area;
(3) recognition of hospital mergers and terminations that influence a
hospital seeking SCH status; (4) including competing hospitals within a
35-mile radius of the requesting hospital as opposed to a 35-road-mile
distance; (5) obtaining patient origin data from competing hospitals,
(6) timeliness of SCH approvals; (7) SCH status for hospitals with
fewer than 50 beds; (8) CAHs as like hospitals; (9) the effect of wage
index reclassifications on a hospital's SCH status; and (10) the use of
affidavits and other certifications in
[[Page 39876]]
verifying time and distance when applying for SCH status.
Response: We would like to reiterate that in the proposed rule we
were restating historical and current policy and criteria for SCHs. We
were not proposing new SCH policies or criteria, or revisions to
existing policies or criteria. Rather, we were striving to publish
criteria that has been developed over the past several years in one
location for the reader's benefit.
First, we appreciate the input concerning a hospital's access to
alternative data when a cost report from a prior year may not be
readily available. We will take this comment into consideration in
working with the fiscal intermediaries in the future to adjust a SCH's
payments.
Second, we believe that, using discharge data available on the
MedPAR file, we can accurately determine a hospital's service area
based on the zip codes that contain the highest number of discharges
for that facility and rank those zip codes accordingly. Several
commenters suggested that we use patient destination data that are
available in some States and, also, that we not be concerned if these
data were not available based on a hospital's cost reporting period. As
in other aspects of the Medicare program, we must rely on data that are
consistent, verifiable by the fiscal intermediaries, and nationally
available so that no one hospital or group of hospitals receives a
distinct advantage by using an alternative source of data that is not
widely available. Therefore, we believe that it is appropriate to
determine the hospital's service area based on Medicare discharges.
Third, if a hospital chooses to have a merger recognized in its
request for SCH status, or, likewise, a hospital termination, then it
is free to wait until its cost report data reflects these changes.
Then, CMS will consider the data in light of these facts.
Fourth, we believe it is reasonable to examine a hospital's
competitors within a 35-mile radius. Most competing hospitals will not
be at the outer limit of the 35-mile radius, and, if these hospitals
are not truly competitors, the discharge data will bear out that fact.
Also, we examine a hospital's service area based on discharges within
zip code areas, and, often, this will exceed a 35-mile radius.
Therefore, we believe the 35-mile radius is reasonable.
Fifth, we realize that obtaining patient origin data from competing
hospitals may be a difficult proposition, which is why CMS offers to
provide this information for the requesting hospital in
Sec. 412.92(b)(1)(iii)(A). CMS' data are based on Medicare discharges.
Sixth, approvals of SCH status are effective prospectively. There
are several ways in which a hospital may qualify as a SCH, and fiscal
intermediaries are required to collect and examine detailed
documentation which sometimes requires the assistance of our regional
or central office staff. We appreciate the fact that hospitals are
concerned that their applications be approved in a timely manner, and
we will make every effort to work diligently with our contractors as
well as our regional offices to achieve that goal.
Seventh, a commenter suggested that we should be more specific when
defining the criteria under which a hospital with fewer than 50 beds
could qualify as an SCH at Sec. 412.92(a)(ii). We will take this into
consideration as we develop further criteria in the future. In the
meantime, we will continue to work closely with our fiscal
intermediaries in approving a hospital's SCH status under this
provision.
Eighth, we do not consider CAHs like hospitals to be SCHs. CAHs are
generally smaller with a very limited length of stay, while SCHs
operate as full-service acute-care hospitals.
Ninth, a hospital's status as an SCH is not affected by a wage
index reclassification approved by the MGCRB. A hospital's SCH status
is affected by an approval for a standardized amount reclassification
only, as a reclassification for purposes of a hospital's base payment
rate changes its status for all inpatient hospital prospective payment
purposes except the wage index.
Finally, hospitals are encouraged to provide as much documentation
as possible to assist the fiscal intermediary and CMS in evaluating
requests for SCH status. The more complete the documentation, the
quicker a decision can be rendered. If a hospital can provide
affidavits or other verification of mileage, distances, competing
hospital locations, etc., then it is encouraged to do so.
B. Rural Referral Centers (Sec. 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act, the
regulations at Sec. 412.96 set 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 amount rather than the rural standardized
amount. Although the other urban and rural standardized amounts were
the same for discharges beginning with that date, rural referral
centers would continue to receive special treatment under both the
disproportionate share hospital (DSH) payment adjustment and the
criteria for geographic reclassification.
Section 401 of Public Law 106-113 amended section 1886(d)(8) of the
Act by adding subparagraph (E), which creates a mechanism, separate and
apart from the MGCRB, permitting an urban hospital to apply to the
Secretary to be treated as being located in the rural area of the State
in which the hospital is located. The statute directs the Secretary to
treat a qualifying hospital as being located in the rural area for
purposes of provisions under section 1886(d) of the Act. Congress
clearly intended hospitals that become rural under section
1886(d)(8)(E) of the Act to receive some benefit as a result. In
addition, one of the criteria under section 1886(d)(8)(E) of the Act is
that the hospital would qualify as an SCH or a rural referral center if
it were located in a rural area. An SCH would be eligible to be paid on
the basis of the higher of its hospital-specific rate or the Federal
rate. On the other hand, the only benefit under section 1886(d) of the
Act for an urban hospital to become a rural referral center would be
waiver of the proximity requirements that are otherwise applicable
under the MGCRB process, as set forth in Sec. 412.230(a)(3)(i).
In the August 1, 2000 final rule (65 FR 47089), we stated that we
believed Congress contemplated that hospitals might seek to be
reclassified as rural under section 1886(d)(8)(E) of the Act in order
to become rural referral centers so that the hospitals would be exempt
from the MGCRB proximity requirement and could be reclassified by the
MGCRB to another urban area. Therefore, in that final rule we sought a
policy approach that would appropriately address our concern that these
urban to rural redesignations not be utilized inappropriately, and that
would benefit hospitals seeking to reclassify under the MGCRB process
by achieving rural referral center status. (We became aware of several
specific hospitals that were rural referral centers for FY 1991, but
subsequently lost their status when the county in which they were
located became urban, and had expressed their wish to be redesignated
as a rural referral center in order to be eligible to reclassify.)
Accordingly, in light of section 1886(d)(8)(E) of the Act and the
language in the accompanying Conference Report, effective as of October
1, 2000, hospitals located in what is now an urban area, if they were
ever a rural referral center, were reinstated to rural referral center
status.
[[Page 39877]]
In addition, as discussed in 62 FR 45999 and 63 FR 26317, under
section 4202 of Public Law 105-33, a hospital that was classified as a
rural referral center for FY 1991 is to be classified as a rural
referral center for FY 1998 and later years so long as that hospital
continued to be located in a rural area and did not voluntarily
terminate its rural referral center status. Otherwise, a hospital
seeking rural referral center status must satisfy applicable criteria.
One of the criteria under which a 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 requirement can qualify as a
rural referral center if the hospital meets two mandatory prerequisites
(specifying a minimum case-mix index and a minimum number of
discharges) and at least one of three optional criteria (relating to
specialty composition of medical staff, source of inpatients, or
referral volume). With respect to the two mandatory prerequisites, 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 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 CMS 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
for FY 2002 in the May 4 proposed rule included all urban hospitals
nationwide, and the proposed regional values for FY 2002 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). Those values were based on discharges occurring during
FY 2000 (October 1, 1999 through September 30, 2000) and included bills
posted to CMS's records through December 2000. (The proposed rule
language erroneously cited the period as FY 1999 (October 1, 1998
through September 30, 1999.)
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, 2001, must have a case-mix index value for FY 2000 that is
at least--
1.3286; or
The median case-mix index value for urban hospitals
(excluding hospitals with approved teaching programs as identified in
Sec. 412.105) calculated by CMS for the census region in which the
hospital is located. (See the table set forth in the May 4, 2001
proposed rule at 66 FR 22687.)Based on the latest data available (FY
2000 bills received through March 31, 2001), 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, 2001, must have a case-mix
index value for FY 2000 that is at least--
1.3289; or
The median case-mix index value for urban hospitals
(excluding hospitals with approved teaching programs as identified in
Sec. 412.105) calculated by CMS for the census region in which the
hospital is located. The final 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).................... 1.2381
2. Middle Atlantic (PA, NJ, NY)............................ 1.2319
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 1.3055
4. East North Central (IL, IN, MI, OH, WI)................. 1.2588
5. East South Central (AL, KY, MS, TN)..................... 1.2530
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 1.1690
7. West South Central (AR, LA, OK, TX)..................... 1.2443
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 1.3275
9. Pacific (AK, CA, HI, OR, WA)............................ 1.2991
------------------------------------------------------------------------
Hospitals seeking to qualify as rural referral centers or those
wishing to know how their case-mix index value compares to the criteria
should obtain hospital-specific case-mix values from their fiscal
intermediaries. Data are available on the Provider Statistical and
Reimbursement (PS&R) System. In keeping with our policy on discharges,
these case-mix index values are computed based on all Medicare patient
discharges subject to DRG-based payment.
2. Discharges
Section 412.96(c)(2)(i) provides that CMS will set forth the
national and regional numbers of discharges in each year's annual
notice of prospective payment rates for purposes of determining rural
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. However, in
the May 4 proposed rule, we proposed to update the regional standards
based on discharges for urban hospitals' cost reporting periods that
began during FY 2000 (that is, October 1, 1999 through September 30,
2000). (The proposed rule language erroneously cited the period as FY
1999 (October 1, 1998 through September 30, 1999.) 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,
2001, must have as the number of discharges for its cost reporting
period that began during FY 2000 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. (See the table set
forth in the May 4, 2001 proposed rule at 66 FR 22687.)
[[Page 39878]]
Based on the latest discharge data available for FY 2000, the final
median number of discharges for urban hospitals by census region areas
are as follows:
------------------------------------------------------------------------
Number of
Region Discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)................. 7,064
2. Middle Atlantic (PA, NJ, NY)......................... 8,488
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA,WV)... 8,562
4. East North Central (IL, IN, MI, OH, WI).............. 7,616
5. East South Central (AL, KY, MS, TN).................. 6,276
6. West North Central (IA, KS, MN, MO, NE, ND, SD)...... 5,210
7. West South Central (AR, LA, OK, TX).................. 6,196
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............ 8,878
9. Pacific (AK, CA, HI, OR, WA)......................... 7,106
------------------------------------------------------------------------
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, 2001, must have at least 3,000 discharges for its cost
reporting period that began during FY 2000.
We did not receive any comments on the criteria for rural referral
centers.
C. Indirect Medical Education (IME) Adjustment (Sec. 412.105)
1. IME Adjustment Factor Formula Multiplier (Section 111 of Public Law
106-113 and section 302 of Public Law 106-554 and Sec. 412.105(d)(3)).
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. The
additional payment is based in part on the applicable IME adjustment
factor. The IME adjustment factor is calculated using a hospital's
ratio of residents to beds, which is represented as r, and a
multiplier, which is represented as c, in the following equation: c x
[(1 + r)\.405\-1]. The formula is traditionally described in terms of a
certain percentage increase in payment for every 10-percent increase in
the resident-to-bed ratio.
Section 302 of Public Law 106-554 amended section 1886(d)(5)(B) of
the Act to modify the transition for the IME formula multiplier, or c,
that was first established by Public Law 105-33 and revised by Public
Law 106-113.
As discussed in the August 1, 2000 final rule and the June 13, 2001
interim final rule with comment period, section 111(a) of Public Law
106-113 revised the formula multiplier for discharges occurring during
FY 2001 (established under Public Law 105-33 at 1.6) to 1.54. However,
section 302(b) of Public Law 106-554 provides a special payment rule
which states that, for discharges occurring on or after April 1, 2001
and before October 1, 2001, IME payments are to be made as if `c'
equaled 1.66, rather than 1.54. The multiplier of 1.54 for the first 6
months of FY 2001 represents a 6.25 percent increase in the level of
the IME adjustment for every 10 percent increase in the resident-to-bed
ratio, and the multiplier for the second 6 months of FY 2001 represents
a 6.75 percent increase in the level of the IME adjustment for every 10
percent increase in the resident-to-bed ratio. This results in an
aggregate 6.5 percent increase for every 10 percent increase in the
resident-to-bed ratio for FY 2001. Section 547(a)(2) of Public Law 106-
554 provides further clarification that these payment increases will
not apply to discharges occurring after FY 2001 and will not be taken
into account in calculating the payment amounts applicable for
discharges occurring after FY 2001. In the June 13 interim final rule,
we revised Sec. 412.105(d)(3)(v) to reflect the additional payment
provided for discharges occurring during FY 2001 under section 302(b)
of Public Law 106-554.
As discussed in the May 4, 2001 proposed rule, section 302(a) of
Public Law 106-554 provides that, for discharges occurring during FY
2002, the formula multiplier is 1.6. For discharges occurring during FY
2003 and thereafter, the formula multiplier is 1.35. As explained
above, section 302(b) of Public Law 106-554 provides for a special
payment rule which states that, for discharges occurring on or after
April 1, 2001 and before October 1, 2001, IME payments are to be made
as if ``c'' equaled 1.66 rather than 1.54. The multiplier of 1.6 for FY
2002 represents a 6.5 percent increase for every 10 percent increase in
the resident-to-bed ratio. The multiplier for FY 2003 and thereafter
(1.35) represents a 5.5-percent increase for every 10-percent increase
in the resident-to-bed ratio. In the May 4 proposed rule, we proposed
to revise Sec. 412.105(d)(3)(vi) to reflect the change in the formula
multiplier for FY 2002 to 1.6 as made by section 302(a) of Public Law
106-554 for discharges occurring during FY 2002. We also proposed to
add Sec. 412.105(d)(3)(vii) to incorporate the formula multiplier of
1.35 for discharges occurring on or after October 1, 2002.
We did not receive any comments on the IME formula provisions of
the June 13 interim final rule with comment period or the proposed
amendments under the May 4 proposed rule. Therefore, we are adopting
both changes to Sec. 412.105(d)(3) as final without change.
2. Resident-to-Bed Ratio Cap (Sec. 412.105(a)(1))
In the May 4, 2001 proposed rule, we indicated that it had come to
our attention that there is some misunderstanding about
Sec. 412.105(a)(1) regarding the determination of the resident-to-bed
ratio that is used in calculating the IME adjustment. Section
4621(b)(1) of Public Law 105-33 amended section 1886(d)(5)(B) of the
Act by adding a new clause (vi) to provide that, effective for cost
reporting periods beginning on or after October 1, 1997, the resident-
to-bed ratio may not exceed the ratio calculated during the prior cost
reporting period (after accounting for the cap on the hospital's number
of full-time equivalent (FTE) residents). We implemented this policy in
the August 29, 1997 final rule with comment period (62 FR 46003) and
the May 12, 1998 final rule (63 FR 26323) under regulations at
Sec. 412.105(a)(1). Existing Sec. 412.105(a)(1) specifies that
``[e]xcept for the special circumstances for affiliated groups and new
programs described in paragraphs (f)(1)(vi) and (f)(1)(vii) of this
section, for a hospital's cost reporting periods beginning on or
[[Page 39879]]
after October 1, 1997, this ratio may not exceed the ratio for the
hospital's most recent prior cost reporting period.'' In the May 4
proposed rule, we proposed to clarify Sec. 412.105(a)(1) to add a
provision that this ratio may not exceed the ratio for the hospital's
most recent prior cost reporting period after accounting for the cap on
the number of FTE residents.
In general, the resident-to-bed ratio from the prior cost reporting
period, which is to be used as the cap on the resident-to-bed ratio for
the current payment cost reporting period, should only include an FTE
count subject to the FTE cap on the number of allopathic and
osteopathic residents, but is not subject to the rolling average. (An
explanation of rolling average appears in section IV.H.3. of this
preamble.)
The following illustrates the steps for determining the resident-
to-bed ratio for the current payment year cost reporting period and the
cap on the resident-to-bed ratio:
Current payment year cost reporting period resident-to-bed ratio:
Step 1. Determine the hospital's number of FTE residents in the
current payment year cost reporting period.
Step 2. Compare the number of allopathic and osteopathic FTEs from
step 1 to the hospital's FTE cap (Sec. 412.105(f)(1)(iv)). If the
number of allopathic and osteopathic FTEs from step 1 exceeds the FTE
cap, replace it with the number of FTEs in the FTE cap. Add any dental
and podiatry FTEs from step 1 to the capped allopathic and osteopathic
FTE count.
Step 3. Determine the 3-year rolling average of the FTE residents
using the FTEs from the current payment year cost reporting period and
the prior two cost reporting periods (subject to the FTE cap in each
cost reporting period). (Include podiatry and dental residents, and
exclude residents in new programs in accordance with
Sec. 412.105(f)(1)(iv) and revised (f)(1)(v). Residents in new programs
are added to the quotient of the rolling average.)
Step 4. Determine the hospital's number of beds (see
Sec. 412.105(b)) in the current payment year cost reporting period.
Step 5. Determine the ratio of the number of FTEs from step 3 to
the number of beds from step 4. The lower of this resident-to-bed ratio
or the resident-to-bed ratio cap (calculated below) from the
immediately preceding cost reporting period is used to calculate the
hospital's IME adjustment factor for the current payment year cost
reporting period.
Resident-to-bed ratio cap:
Step 1. Determine the hospital's number of FTE residents in its
cost reporting period that immediately precedes the current payment
year cost reporting period.
Step 2. Compare the number of allopathic and osteopathic FTEs from
step 1 to the hospital's FTE cap. If the number of allopathic and
osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the
number of FTEs in the FTE cap. Add any dental and podiatry FTEs from
step 1 to the capped allopathic and osteopathic FTE count. (If there is
an increase in the number of FTEs in the current payment year cost
reporting period due to a new program or an affiliation agreement,
these FTEs are added to FTEs in the preceding cost reporting period
after applying the FTE cap.)
Step 3. Determine the hospital's number of beds (Sec. 412.105(b))
in its cost reporting period that immediately precedes the current
payment year cost reporting period.
Step 4. Determine the ratio of the number of FTEs in step 2 to the
number of beds in step 3. This ratio is the resident-to-bed ratio cap
for the current payment year cost reporting period.
Step 5. Compare the resident-to-bed ratio cap in step 4 to the
resident-to-bed ratio in the current payment year cost reporting
period. The lower of the resident-to-bed ratio from the current payment
year cost reporting period or the resident-to-bed ratio cap from the
immediately preceding cost reporting period is used to calculate the
hospital's IME adjustment factor for the current payment year cost
reporting period.
We note that the resident-to-bed ratio cap is a cap on the
resident-to-bed ratio calculated for all residents, including
allopathic, osteopathic, dental, and podiatry residents (63 FR 26324,
May 12, 1998). However, as described in existing Sec. 412.105(a)(1),
the resident-to-bed ratio cap may be adjusted to reflect an increase in
the current cost reporting period's resident-to-bed ratio due to
residents in a new GME program or an affiliation agreement. While an
exception does not apply if the resident-to-bed ratio increases because
of an increase in the number of podiatry or dentistry residents or
because of a change in the number of beds, the ratio could increase
after a one-year delay. An increase in the current cost reporting
period's ratio (while subject to the FTE cap on the overall number of
allopathic and osteopathic residents) thereby establishes a higher cap
for the following cost reporting period.
The following is an example of the application of the cap on the
resident-to-bed ratio:
Example--Part 1:
Assume Hospital A has 50 FTEs in its cost reporting
period ending September 30, 1996, thereby establishing an IME FTE
resident cap of 50 FTEs.
In its cost reporting period of October 1, 1996 to
September 30, 1997 (the prior year), it has 50 FTEs and 200 beds, so
that its resident-to-bed ratio for this period is 50/200 = .25.
In the (current year) cost reporting period of October
1, 1997 to September 30, 1998 (the first cost reporting period in
which the FTE resident cap, the resident-to-bed ratio cap, and the
rolling average apply), Hospital A has 50 FTEs and 200 beds.
Hospital A's FTEs do not exceed its FTE cap, so its
current number of FTEs (50) is used to calculate the 2-year rolling
average: (50 + 50)/2 = 50.
The result of the rolling average is used as the
numerator of the resident-to-bed ratio. Thus, the resident-to-bed
ratio is 50/200 = .25.
.25 is compared to the resident-to-bed ratio from the
prior period of October 1, 1996 to September 30, 1997. Because the
FTE resident cap and the rolling average were not yet effective in
the period of October 1, 1996 to September 30, 1997, that period s
resident-to-bed ratio does not have to be recalculated to account
for the FTE resident cap. Accordingly, the resident-to-bed ratio cap
for October 1, 1997 to September 30, 1998 is .25.
Because the resident-to-bed ratio does not exceed the
prior year ratio, Hospital A would use the resident-to-bed ratio of
.25 to determine the IME adjustment in its cost reporting period of
October 1, 1997 to September 30, 1998.
Example--Part 2:
In the (current year) cost reporting period of October
1, 1998 to September 30, 1999, Hospital A adds 1 podiatric and 1
dental resident, so that it has a total of 52 FTEs and 200 beds.
Since the FTE resident cap only includes allopathic and osteopathic
residents, Hospital A has not exceeded its FTE resident cap with the
addition of a podiatric and a dental resident.
Accordingly, the (now) 3-year rolling average would be
(52 + 50 + 50)/3 = 50.67.
50.67 is used in the numerator of the current payment
year's resident-to-bed ratio, so that the resident-to-bed ratio is
50.67/200 = .253.
.253 is compared to the resident-to-bed ratio from the
prior year's cost reporting period of October 1, 1997 to September
30, 1998 that is recalculated to account for the FTE resident cap.
Because Hospital A did not exceed its FTE resident cap of 50 FTEs in
this period of October 1, 1997 to September 30, 1998, the
recalculated resident-to-bed ratio would be 50/200 = .25.
Compare the current year resident-to-bed ratio (.253)
to the resident-to-bed ratio cap (.25); .253 does exceed .25.
Therefore, the resident-to-bed ratio in the period of
October 1, 1998 to September 30, 1999 is capped at .25, which is to
be used in calculating Hospital A s IME adjustment for October 1,
1998 to September 30, 1999.
Example--Part 3:
In the cost reporting period of October 1, 1999 to
September 30, 2000, Hospital A adds
[[Page 39880]]
2 internal medicine residents so that it has a total of 54 FTEs and
200 beds. While podiatric and dental residents are not included in
the FTE resident cap, internal medicine residents are included.
Hospital A has exceeded its IME FTE resident cap of 50 by 2 FTEs.
Thus, 2 FTEs are excluded from the FTE count.
Accordingly, the rolling average would be (52 + 52 +
50)/3 = 51.33.
51.33 is used in the numerator of the resident-to-bed
ratio, so that the resident-to-bed ratio is 51.33/200 = .257.
.257 is compared to the resident-to-bed ratio from
October 1, 1998 to September 30, 1999 that is recalculated to only
account for the FTE resident cap. The recalculated resident-to-bed
ratio would be 50 allopathic or osteopathic FTEs plus 1 podiatric
and 1 dental resident, which is 52/200 = .26.
.26 is the resident-to-bed ratio cap for October 1,
1999 to September 30, 2000. .257 does not exceed .26.
Therefore, the resident-to-bed ratio in the period of
October 1, 1998 to September 30, 1999 is .257, which is to be used
in calculating this period s IME adjustment.
If a hospital starts a new GME program, the adjustment to the
resident-to-bed ratio cap applies for the period of years equal to the
minimum accredited length for each new program started. (For example,
for a new internal medicine program, the period of years equals 3; for
a new surgery program, the period of years equals 5.) Within these
program years, the number of new FTE residents in the current cost
reporting period is added to the FTE resident count used in the
numerator of the resident-to-bed ratio from the previous cost reporting
period. The lower of the resident-to-bed ratio from the current cost
reporting period or the adjusted resident-to-bed ratio from the
preceding cost reporting period is used to calculate the hospital's IME
adjustment for the current cost reporting period. If a hospital
subsequently continues to expand its program, the numerator of the
resident-to-bed ratio from the preceding cost reporting period would
not be adjusted to reflect these additional residents. However, an
increase in the ratio of the current cost reporting period would
establish a higher cap for the following cost reporting period.
We also proposed to add a provision that the exception for new
programs described in Sec. 412.105(f)(1)(vii) applies for the period of
years equal to the minimum accredited length for each new program.
Similarly, if a hospital increases the number of FTE residents in
the current cost reporting period because of an affiliation agreement,
the number of additional FTEs is added to the FTE resident count used
in the numerator of the resident-to-bed ratio from the previous cost
reporting period. The lower of the resident-to-bed ratio from the
current cost reporting period or the adjusted resident-to-bed ratio
from the preceding cost reporting period is used to calculate the
hospital's IME adjustment for the current cost reporting period.
Comment: Several commenters addressed our clarifications to the
regulations at Sec. 412.105(a)(1) regarding the cap on the resident-to-
bed ratio. One commenter stated that the explanation in the proposed
rule regarding the resident-to-bed ratio was thorough. Another
commenter expressed appreciation for the inclusion of examples in the
proposed rule's preamble. One commenter noted that, in the proposed
rule under step 2 of the example of the calculation of the resident-to-
bed ratio cap, we indicate that the lesser of the prior year FTEs or
the FTE cap is used in the numerator of the resident-to-bed ratio. The
commenter noted that we do not specify that, while the FTE cap only
applies to allopathic and osteopathic FTEs, dentistry and podiatry FTEs
should be included in the numerator of the resident-to-bed ratio. The
commenter asked that we specify that the prior year podiatry and
dentistry FTEs must be added to the FTE count used in the resident-to-
bed ratio after the FTE cap has been applied.
Response: We agree with the commenter concerning the inclusion of
dental and podiatry FTEs in step 2, and we have clarified the language
in step 2 of the examples of both the current year resident-to-bed
ratio and the resident-to-bed ratio cap calculation in the preamble of
this final rule. Specifically, we state, ``Compare the number of
allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap.
If the number of allopathic and osteopathic FTEs from step 1 exceeds
the FTE cap, replace it with the FTE cap. Add any dental or podiatry
FTEs from step 1 to the capped allopathic and osteopathic FTE count.''
Furthermore, we are revising the proposed changes to the regulations
text at Sec. 412.105(a)(1) to state that ``. . . this ratio may not
exceed the ratio for the hospital's most recent prior cost reporting
period after accounting for the cap on the number of allopathic and
osteopathic residents as described in paragraph (f)(1)(iv) of this
section, and adding to the capped numerator any dental and podiatric
full-time equivalent residents. . . .''
Comment: One commenter noted that, in clarifying the regulations at
Sec. 412.105(a)(1) regarding the resident-to-bed ratio cap, we added
that the exception to the resident-to-bed ratio cap ``. . . for new
programs . . . applies for the period of years equal to the minimum
accredited length for that type of program'' (emphasis added). The
commenter asked how we would apply the exception to the resident-to-bed
ratio cap in a situation where a hospital has started several new
programs with varying minimum accredited lengths.
Response: The exception at proposed Sec. 412.105(a)(1) for new
programs allows a hospital to add a full complement of residents and
complete the initial cycle of a program before residents in the new
programs are included in the application of the resident-to-bed ratio
cap. In a situation where a hospital has started several new programs
under Sec. 412.105(f)(1)(vii), we would apply the exception to the
resident-to-bed ratio cap to each new program individually based on
each program's minimum accredited length. For example, if a hospital
simultaneously starts a new internal medicine program (which has a
minimum accredited length of 3 years) and an anesthesiology program
(which has a minimum accredited length of 4 years), the FTE residents
in the new internal medicine program will be subject to the resident-
to-bed ratio cap in the fourth program year of the internal medicine
program, while the anesthesiology FTE residents would still be excluded
from the resident-to-bed ratio cap in the fourth program year of the
anesthesiology programs. However, in subsequent program years, the
anesthesiology FTE residents would be subject to the resident-to-bed
ratio cap, as well.
The rules regarding the exception from the rolling average
calculation for IME are the same for direct GME. The proposed revised
regulations at Sec. 412.105(f)(1)(v) and Sec. 413.86(g)(5) in the May
4, 2001 proposed rule state that FTE residents in a new program are
excluded from the rolling average calculation for the period of years
equal to the minimum accredited length for the type of program. In this
final rule, we are revising the regulations regarding the exceptions to
the resident-to-bed ratio cap and the rolling average calculation for
both IME and direct GME to clarify that these exceptions apply to each
new program individually for which the FTE cap may be adjusted based on
each program's minimum accredited length (Sec. 412.105(a)(1),
412.105(f)(1)(v), and 413.86(g)(5)(v)).
Comment: One commenter asserted that, in the proposed rule, it is
inconsistent to account for both the FTE cap and the rolling average
count of residents in the current year resident-to-bed ratio, but
account for only the FTE cap in the resident-to-bed ratio cap
[[Page 39881]]
(which is the prior year's ratio). The commenter stated that their
willingness to support the proposed rule depended on whether the
residency program is increasing or decreasing its FTEs every year.
Response: Section 1886(d)(5)(B)(v)(I) of the Act, as amended by
Public Law 105-33, states that the resident-to-bed ratio ``may not
exceed the ratio of the number of interns and residents, subject to the
limit under clause (v), with respect to the hospital for its most
recent cost reporting period to the hospital's available beds . . .
during that cost reporting period . . .'' (emphasis added). Clause (v)
is the FTE cap requirement; the statute does not specify clause
(vi)(II), which is the rolling average requirement, in relation to the
resident-to-bed ratio cap. Accordingly, the implementing regulations
require that the resident-to-bed ratio cap should only account for the
cap on the number of FTEs.
In addition, we note that the commenter is mistaken in indicating
that the rules regarding the determination of the resident-to-bed ratio
and the resident-to-bed ratio cap are proposed rules. These rules have
been in place based on the statute since the effective date of Public
Law 105-33. We simply took the opportunity in the proposed rule
published on May 4, 2001 to further clarify our existing policy because
we realized that there was some confusion surrounding these rules.
Comment: One commenter noted that, since under the provisions of
Sec. 413.86(g)(6)(i), the FTE cap for new programs is established based
on the number of residents in the third year of the first program's
existence, it follows that the FTE cap on the residents in the new
programs is effective in the fourth program year. The commenter asked
if the application of the cap is delayed until the expiration of the
minimum accredited length of the new programs.
Response: The application of the FTE adjusted caps for new programs
under Sec. 413.86(g)(6)(i) and (g)(6)(ii) are not delayed until the
expiration of the minimum accredited length of the new programs. Only
the application of the resident-to-bed ratio cap for IME and the
rolling average for both IME and direct GME are dependent upon the
minimum accredited length of each new program. The regulations at
Sec. 413.86(g)(6)(i) state that the cap for new programs will 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'' (emphasis added).
In general, when a hospital qualifies for a cap adjustment under
Sec. 413.86(g)(6)(i), the hospital has three years from the time that a
resident first begins training in the first new program to establish
its FTE cap. The first day of the fourth program year, the FTE cap on
that first program, and any other programs that may have been started
within the initial three years of that first program, is permanently
established and takes effect.
For example, if a hospital that qualifies for a cap adjustment
under Sec. 413.86(g)(6)(i) starts a newly accredited dermatology
program on July 1, 2001, and then starts a newly accredited
anesthesiology program on July 1, 2002, the cap for both programs, and
for the hospital as a whole, will be adjusted as of July 1, 2004, the
first day of the fourth program year of dermatology, which is the first
program that the hospital started. The hospital's cap will be based on
the sum of: (a) The product of the highest number of residents in
either PGY1, PGY2, or PGY3 in the third year of the dermatology program
and 4 years (the minimum accredited length of dermatology); and (b) the
product of the highest number of residents in either PGY1 or PGY2 for
the anesthesiology program and 4 years (the minimum accredited length
for anesthesiology). Any programs begun after the first program's start
date but before the fourth program year of the first program will not
have a full 3 years before the hospital's cap is permanently adjusted.
The rules under Sec. 413.86(g)(6)(ii) differ for hospitals that
qualify for an FTE cap adjustment for new programs started on or after
January 1, 1995 and on or before August 5, 1997. Section
413.86(g)(6)(ii) states that the FTE cap adjustment 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 the program based on the
minimum accredited length for the type of program'' (emphasis added).
In contrast to hospitals that qualify for a cap adjustment under
Sec. 413.86(g)(6)(i), where the cap for the hospital takes effect for
all programs in the fourth program year of the first program that was
started by the hospital, hospitals that qualify for an FTE cap
adjustment under Sec. 413.86(g)(6)(ii) have a full 3 years to grow each
new program, as long as those programs all started training residents
or received accreditation between January 1, 1995 and on or before
August 5, 1997. The adjustment to the cap for each of those new
programs would be applied individually, beginning with the first day of
the fourth program year of each new program. (We note that rural
hospitals that qualify for a cap adjustment under
Sec. 413.86(g)(6)(iii) may receive an FTE cap adjustment in the same
manner as hospitals that qualify for the cap adjustment under
Sec. 413.86(g)(6)(ii), except that rural hospitals may receive this
adjustment for programs started after August 5, 1997).
For example, assume a hospital that qualifies for a cap adjustment
under Sec. 413.86(g)(6)(ii) started a newly accredited internal
medicine program on July 1, 1996, and a newly accredited dermatology
program on July 1, 1997. The adjustment to the hospital's FTE cap
because of the internal medicine program was effective July 1, 1999
(the first day of the fourth program year of internal medicine), and
the cap adjustment resulting from the dermatology program was effective
July 1, 2000 (the first day of the fourth program year for
dermatology). The hospital's ultimate FTE cap is the sum of the FTE cap
based on FTEs in the hospital's most recent cost reporting period
ending on or before December 31, 1996, and the cap adjustments for the
internal medicine and dermatology programs. (We note that since the
internal medicine program began in 1996, depending on the hospital's
cost reporting period, a portion of those FTEs may have already been
included in the hospital's FTE cap. That portion that was included in
the FTE cap must be subtracted from the cap adjustment that was
calculated for the internal medicine program to avoid any double
counting of the FTEs). The hospital's adjusted cap will be based on the
sum of: (a) the product of the highest number of internal medicine
residents in either PGY1, PGY2, or PGY3 in the third year of the
internal medicine program and three (the minimum accredited length of
internal medicine); and (b) the product of the highest number of
dermatology residents in either PGY1, PGY2, or PGY3 for the dermatology
program and four (the minimum accredited length for dermatology).
In summary, we reiterate that the application of the FTE cap
adjustments for new programs is not delayed until the program year in
which the minimum accredited length of each program expires. This would
even apply to a new program with a minimum accredited length that
exceeds 3 years. The FTE cap adjustment takes effect on the first day
of the fourth program year of the first new program that was started
[[Page 39882]]
by hospitals qualifying for a cap adjustment under
Sec. 413.86(g)(6)(i). For hospitals qualifying for a cap adjustment
under Sec. 413.86(g)(6)(ii) and (g)(6)(iii), the cap adjustments take
effect on the first day of the fourth program year of each new program.
However, the application of the resident-to-bed ratio cap for IME and
the rolling average for both IME and direct GME are dependent upon the
minimum accredited length of each new program.
Comment: With regard to the counting of residents for IME payment
purposes in nonhospital sites, one commenter stated that although time
spent in nonhospital sites may be included in the IME FTE count
effective for discharges occurring on or after October 1, 1997, the
application of the 1996 FTE cap effectively disallows the current
year's FTEs training in the nonhospital site, because the 1996 FTE cap
was based on residents training only in the hospital. The commenter
added that only those hospitals that are in a position to elect a
Medicare affiliation agreement are able to ``circumvent'' the 1996 FTE
limit; those that cannot are ``penalized.'' The commenter further
stated that the regulatory intent of allowing nonhospital training time
to be counted is not fully met by having only certain hospitals able to
affiliate. The commenter recommended that we should allow hospitals to
recalculate the 1996 IME FTE cap to include those FTEs training in
nonhospital sites, so that hospitals will effectively be able to count
residents currently training in nonhospital sites for IME purposes.
Response: The commenter is addressing a provision in Public Law
105-33 that was implemented in regulations at
Sec. 412.105(f)(1)(ii)(C). We did not propose any substantive changes
to this policy; we simply were correcting an oversight in the
regulations text for IME. (Comments on regulations implementing this
provision were addressed in the May 12, 1998 final rule (63 FR 26323)
and the July 31, 1998 final rule (63 FR 40954).)
3. Conforming Changes (Sec. 412.105(f)(1)(ii)(C) and (f)(1)(v))
In the August 29, 1997 final rule with comment period (62 FR
46003), the May 12, 1998 final rule (63 FR 26323), and the July 31,
1998 final rule (63 FR 40986), to implement the provisions of Public
Law 105-33, we set forth certain policies that affected payment for
both direct and indirect GME. Some of these policies related to the FTE
cap on allopathic and osteopathic residents, the rolling average, and
payment for residents training in nonhospital settings. In the May 4
proposed rule, we indicated that when we amended the regulations under
Sec. 413.86 for direct GME, we inadvertently did not make certain
conforming changes in Sec. 412.105 for IME. We proposed to make the
following conforming changes:
To revise Sec. 412.105(f)(1)(ii)(C) to specify that,
effective for discharges occurring on or after October 1, 1997, the
time residents spend training in a nonhospital setting in patient care
activities under an approved medical residency training program may be
counted towards the determination of full-time equivalency if the
criteria set forth at Sec. 413.86(f)(3) or Sec. 413.86(f)(4), as
applicable, are met.
To revise Sec. 412.105(f)(1)(v) to specify that residents
in new residency programs are not included in the rolling average for a
period of years equal to the minimum accredited length for the type of
program.
In addition, we proposed to revise Sec. 412.105(f)(1)(ix) to
specify, for IME purposes, a temporary adjustment to a hospital's FTE
cap to reflect residents added because of another hospital's closure of
its medical residency program (to conform to the May 4, 2001 proposed
change for GME discussed in section IV.H.5. of this preamble).
We did not receive any comments on these conforming changes and are
adopting them as final.
D. Payments to Disproportionate Share Hospitals (DSH) (Sections 211 and
303 of Public Law 106-554 and Sec. 412.106)
Effective for discharges beginning on or after May 1, 1986,
hospitals that serve a disproportionate number of low-income patients
(the DSH patient percentage as defined in section 1886(d)(5)(F) of the
Act) receive additional payments through the DSH adjustment. Hospitals
that meet the DSH patient percentage criteria are entitled to the DSH
payment adjustment.
1. Qualifying Thresholds for DSHs
In the June 13, 2001 interim final rule with comment period, we
discussed the provisions of section 1886(d)(5)(F)(v) of the Act, as it
existed prior to enactment of Public Law 106-554 and under
Sec. 412.106(c) of the existing regulations, which provided that a
hospital qualified for DSH if the hospital had a DSH patient percentage
equal to:
At least 15 percent for an urban hospital with 100 or more
beds or a rural hospital with 500 or more beds;
At least 40 percent for an urban hospital with fewer than
100 beds;
At least 45 percent for a rural hospital with 100 beds or
fewer, if it is not also classified as an SCH;
At least 30 percent for a rural hospital with more than
100 beds and fewer than 500 beds or which is classified as an SCH; or
The hospital has 100 or more beds, is located in an urban
area, and receives more than 30 percent of its net inpatient revenues
from State and local government sources for the care of indigent
patients not eligible for Medicare or Medicaid.
Section 211(a) of Public Law 106-554 amended section
1886(d)(5)(F)(v) to provide that, beginning with discharges occurring
on or after April 1, 2001, the qualifying threshold is reduced to 15
percent for all hospitals. Therefore, in the June 13 interim final
rule, we revised Sec. 412.106(c) to reflect the change in DSH
qualifying threshold percentages.
Comment: Several commenters responded on the subject of the
calculation of the DSH payment adjustment. These commenters were
concerned about how to apply the threshold changes as of April 1, 2000.
They were also concerned about counting days in the calculation when a
stay crosses over two cost reporting periods. Finally, these commenters
were concerned about counting section 1115 expansion waiver days in the
DSH payment adjustment calculation.
Response: Section 211(a) of Public Law 106-554 amended section
1886(d)(5)(F) of the Act to change the qualifying thresholds for the
DSH payment adjustment to 15 percent for all hospital types, effective
with discharges occurring on or after April 1, 2001. This means that
the legislation is effective with discharges occurring on or after
April 1, 2001, but not before. Therefore, fiscal intermediaries are
required to determine whether a hospital meets the thresholds in place
either before or after April 1, 2001, by applying the DSH patient
percentage in the formula to each separate period. Days are counted
based on the date of discharge. In other words, a hospital stay would
be counted in the cost reporting year during which the patient was
discharged.
Finally, counting section 1115 expansion waiver days in the DSH
payment adjustment calculation was discussed in the August 1, 2000
Federal Register (65 FR 47086). This policy became effective for
discharges occurring on or after January 20, 2000. Therefore, it is
possible that a hospital will qualify for DSH payments as of January
20, 2000, whereas it did not qualify before January 20, 2000, and it
should be paid accordingly. In other words, a hospital in that
situation would receive Medicare DSH payments beginning January 20,
2000.
[[Page 39883]]
2. Calculation of the DSH Payment Adjustment
Section 211(b) of Public Law 106-554 further amended section
1886(d)(5)(F) to revise the calculation of the DSH payment adjustment
for hospitals affected by the revised thresholds as specified in
section 211(a) of the Act. In the June 13 interim final rule with
comment period, we discussed these adjustments, which are effective for
discharges occurring on or after April 1, 2001, as follows:
Urban hospitals with fewer than 100 beds and whose DSH
patient percentage is equal to or greater than 15 percent and less than
19.3 percent receive the DSH payment adjustment determined using the
following formula:
(DSH patient percentage - 15) (.65) + 2.5.
Urban hospitals with fewer than 100 beds and whose DSH
patient percentage is equal to or greater than 19.3 percent receive a
flat add-on of 5.25 percent.
Rural hospitals that are both rural referral centers and
SCHs receive the DSH payment adjustment determined using the higher of
the SCH adjustment or the rural referral center adjustment.
Rural hospitals that are SCHs and are not rural referral
centers and whose DSH patient percentage is equal to or greater than 15
percent and less than 19.3 percent receive the DSH payment adjustment
determined using the following formula:
(DSH patient percentage - 15) (.65) + 2.5.
Rural hospitals that are SCHs and are not rural referral
centers and whose DSH patient percentage is equal to or greater than
19.3 percent and less than 30 percent receive a flat add-on of 5.25
percent.
Rural hospitals that are SCHs and are not rural referral
centers and whose DSH patient percentage is equal to or greater than 30
percent receive 10 percent.
Rural referral centers whose DSH patient percentage is
greater than or equal to 15 percent and less than 19.3 percent receive
the DSH payment adjustment determined using the following formula:
(DSH patient percentage - 15) (.65) + 2.5.
Rural referral centers whose DSH patient percentage is
equal to or greater than 19.3 percent but less than 30 percent receive
a flat add-on of 5.25 percent.
Rural referral centers whose DSH patient percentage is
equal to or greater than 30 percent receive the DSH payment adjustment
determined using the following formula:
(DSH patient percentage--30) (.6) + 5.25.
Rural hospitals with fewer than 500 beds and whose DSH
patient percentage is equal to or greater than 15 percent and less than
19.3 percent receive the DSH payment adjustment using the following
formula:
(DSH patient percentage--15) (.65) + 2.5.
Rural hospitals with fewer than 500 beds and whose DSH
patient percentage is equal to or greater than 19.3 percent receive a
flat add-on of 5.25 percent.
If we calcqulate DSH patient percentages to the hundredth place
(our current practice), these payment formulas result in an anomaly for
some DSH patient percentages just below 19.3 percent (but greater than
19.2 percent). That is, as the percentage values approach 19.3, the DSH
payment adjustment resulting from the formula exceeds 5.25 percent.
This would result in a higher DSH payment adjustment for DSH patient
percentages just below 19.3 than for percentages of 19.3 and above. We
stated in the June 13 interim final rule that, because we believe it
would be contrary to the Congress' intent for hospitals with a DSH
patient percentage of less than 19.3 percent to receive a greater
payment than those hospitals of the same class that have a DSH patient
percentage of 19.3 or greater, we were implementing this provision so
that, for DSH patient percentages below 19.3 for affected hospitals,
the DSH payment adjustment will not exceed 5.25 percent.
In the June 13 interim final rule with comment period, we revised
Sec. 412.106(d) to reflect the changes in the disproportionate share
adjustment.
3. Percentage Reduction to the DSH Payment Adjustment
Section 1886(d)(5)(F)(ix) of the Act, as amended by section 112 of
Public Law 106-113, specifies a percentage reduction in the payments a
hospital would otherwise receive under the DSH payment adjustment
formula. Prior to enactment of section 303 of Public Law 106-554, the
reduction percentages were as follows: 3 percent for FY 2001, 4 percent
for FY 2002, and 0 percent for FY 2003 and each subsequent fiscal year.
Section 303 of Public Law 106-554 revised the amount of the percent
reductions to 2 percent for discharges occurring in FY 2001, and to 3
percent for discharges occurring in FY 2002. The reduction continues to
be 0 percent for FY 2003 and each subsequent fiscal year. Section 303
of Public Law 106-554 contains a special rule for FY 2001: For
discharges occurring on or after October 1, 2000 and before April 1,
2001, the reduction is to be 3 percent, and for discharges occurring on
or after April 1, 2001 and before October 1, 2001, the reduction is to
be 1 percent. Changes made by section 303 with respect to FY 2001
discharges were implemented in the June 13, 2001 interim final rule
with comment period.
We are adopting as final the revisions to Sec. 412.106(e) to
reflect the change in the percentages made by section 303 of Public Law
106-554 that were included in the May 4, 2001 proposed rule and in the
June 13, 2001 interim final rule with comment period. We also are
making a technical change in the heading of paragraph (e).
E. Medicare-Dependent, Small Rural Hospitals (Section 404 of Public Law
106-113 and section 212 of Public Law 106-554 and 42 CFR 412.90(j) and
412.108)
Section 6003(f) of the Omnibus Budget Reconciliation Act of 1989
(Public Law 101-239) added section 1886(d)(5)(G) to the Act and created
the category of Medicare-dependent, small rural hospital (MDH) that are
eligible for a special payment adjustment under the hospital inpatient
prospective payment system. Section 1886(d)(5)(G) of the Act define an
MDH as any hospital that meets all of the following criteria:
The hospital is located in a rural area.
The hospital has 100 or fewer beds.
The hospital is not classified as an SCH (as defined at
Sec. 412.92).
In the hospital's cost reporting period that began during
FY 1987, not less than 60 percent of its inpatient days or discharges
were attributable to inpatients entitled to Medicare Part A benefits.
If the cost reporting period is for less than 12 months, the hospital's
most recent 12-month or longer cost reporting period before the short
period is used.
(For a more detailed discussion, see the April 20, 1990 Federal
Register (55 FR 15154)).
As provided by the law, MDHs were eligible for a special payment
adjustment under the prospective payment system, effective for cost
reporting periods beginning on or after April 1, 1990 and ending on or
before March 31, 1993. Hospitals classified as MDHs were paid using the
same methodology applicable to SCHs, that is, based on whichever of the
following rates yielded the greatest aggregate payment for the cost
reporting period:
The national Federal rate applicable to the hospital.
The updated hospital-specific rate using FY 1982 cost per
discharge.
[[Page 39884]]
The updated hospital-specific rate using FY 1987 cost per
discharge.
Section 13501(e)(1) of the Omnibus Budget Reconciliation Act of
1993 (Public Law 103-66) extended the MDH provision through FY 1994 and
provided that, after the hospital's first three 12-month cost reporting
periods beginning on or after April 1, 1990, the additional payment to
an MDH whose applicable hospital-specific rate exceeded the Federal
rate was limited to 50 percent of the amount by which the hospital-
specific rate exceeded the Federal rate.
Section 4204(a)(3) of Public Law 105-33 reinstated the MDH special
payment for discharges occurring on or after October 1, 1997 and before
October 1, 2001, but did not revise the qualifying criteria for these
hospitals or the payment methodology.
Section 404(a) of Public Law 106-113 extended the MDH provision to
discharges occurring on or after October 1, 2002 and before October 1,
2006. In the August 1, 2000 interim final rule with comment period, we
revised Secs. 412.90(j) and 412.108 to reflect the extension of the MDH
program through FY 2006.
As specified in the June 13, 2001 interim final rule with comment
period, section 212 of Public Law 106-554 provided that, effective with
cost reporting periods beginning on or after April 1, 2001, hospitals
have the option to base MDH eligibility on two of the three most
recently audited cost reporting periods for which the Secretary has a
settled cost report, rather than on the cost reporting period that
began during FY 1987. According to section 212, the criteria for at
least 60 percent Medicare utilization will be met if in at least ``2 of
the 3 most recently audited cost reporting periods for which the
Secretary has a settled cost report'', at least 60 percent of the
hospital's inpatient days or discharges were attributable to
individuals receiving Medicare Part A benefits.
Hospitals that qualify under this provision are subject to the
other provisions already in place for MDHs, that is, the payment
methodology as defined in Sec. 412.108(c) and the volume decrease
provision as defined in Sec. 412.108(d).
A hospital must notify its fiscal intermediary to be considered for
MDH status under this new provision. Any hospital that believes it
meets the criteria to qualify as an MDH, based on at least two of its
three most recently settled cost reports, must submit a written request
to its intermediary. The hospital's request must be submitted within
180 days from the date of the notice of amount of program reimbursement
for the cost reporting period in question. The intermediary will make
its determination and notify the hospital within 180 days from the date
it receives the hospital's request and all of the required
documentation.
In the June 13 interim final rule with comment period, we revised
Sec. 412.108(a)(1)(iii) to reflect the additional option provided by
section 212 of Public Law 106-554.
We received one comment on the proposed regulation change.
Comment: One commenter representing a state hospital association
expressed concern regarding the MDH qualifying process outlined in the
interim final rule. The commenter questioned the timing of the process,
especially that the hospital would be required to apply within 180 days
from the date of the notice of program reimbursement and that the
fiscal intermediary would have up to 180 days in which to make its
decision. The commenter believed that this would not allow hospitals to
qualify by the first cost reporting period beginning on or after the
April 1, 2001, effective date of the new provision. The commenter also
believed that this process would result in a lengthy period of time,
perhaps 2-4 years while the cost report settlement and this process
plays out. The commenter also believed the determination of whether or
not a hospital meets the requirements to become an MDH under this new
provision should be handled in manner consistent with that already in
place. That is, fiscal intermediaries should automatically determine,
using the cost report information they have, whether or not any
additional hospitals would now qualify as an MDH under this new
criteria, rather than putting the burden on the hospitals to apply for
MDH status. The commenter also stated that the fiscal intermediaries
require instruction regarding the calculation of the payment rates in
order to determine which would most benefit the MDHs. The commenter
also believed that the impact analysis understates the number of newly
eligible hospitals under the new MDH provision.
Response: We disagree with the commenter that the process for
approval of new MDHs could take as long as 2 to 4 years. We do agree
with this commenter that hospitals' requests for consideration under
this provision need not be limited to requests submitted within 180
days of the issuance of a notice of amount of program reimbursement,
and we are deleting this requirement from Sec. 412.108(b). This will
eliminate any unintended delay in the time when hospitals could request
MDH status. Therefore, hospitals are free to request MDH status at any
time. We also are revising the time provided for fiscal intermediaries
to make their determination, from 180 days to 90 days. We believe this
will provide sufficient time for review while being responsive to the
commenter's concern that the process not be too lengthy. Similar to the
approval period for SCHs as described above, MDH status and the
associated payment adjustment are effective 30 days after written
notification to the MDH.
We believe it is most appropriate, and consistent with procedures
for SCH and rural referral center designation, to require hospitals to
request consideration as a MDH, rather than placing this requirement
with the fiscal intermediaries. We will further clarify the MDH policy
and process, including the change noted above, through future Program
Memoranda.
With respect to the commenter's concern that our impact analysis
underestimates the number of newly eligible hospitals under the new
provision, we noted in the June 13, 2001 interim final rule with
comment period that our most recent data available were 1998, and we
were, therefore, unable to estimate the impacts using more recent data.
Therefore, the actual impact of this provision may be different as the
fiscal intermediaries evaluated hospitals' requests using more recent
data.
F. Reclassification of Certain Urban Hospitals as Rural Hospitals
(Sections 401(a) and (b) of Public Law 106-113 and 42 CFR 412.63(b),
412.90(e), 412.102, and 412.103)
1. Permitting Reclassification of Certain Urban Hospitals as Rural
Hospitals
Under Medicare law, the location of a hospital can affect its
payment methodology as well as whether the facility qualifies for
special treatment both for operating and for capital payments. Whether
a facility is situated in an urban or a rural area will, for example,
affect payments based on the wage index values and Federal standardized
amounts specific to the area. Similarly, the percentage increase in
payments made to hospitals that treat a disproportionate share of low-
income patients is based, in part, on its urban/rural status, as are
determinations regarding a hospital's qualification as an SCH, rural
referral center, critical access hospital (CAH), or other special
category of facility. Section 1886(d)(2)(D) of the Act defines an
``urban area'' as an area within a MSA as defined by the Office of
Management and Budget. The same
[[Page 39885]]
provision defines a ``large urban area,'' with respect to any fiscal
year, as an urban area that the Secretary determines (in the
publications described in section 1886(e)(5) of the Act before the
fiscal year) has a population of more than 1 million as determined
based on the most recent available published Census Bureau data.
Section 1886(d)(2)(D) of the Act further defines a ``rural area'' as an
area that is outside of a ``large'' urban area or ``other'' urban area.
Since FY 1995, the average standardized amount for hospitals located in
rural areas and ``other'' urban areas has been equal, as provided for
in section 1886(b)(3)(B)(i)(X) of the Act.
Several provisions of the Act provide procedures under which a
hospital can apply for reclassification from one geographic area to
another. Section 1886(d)(8)(B) of the Act, which provides that if
certain conditions are met, the Secretary shall treat a hospital
located in a rural county adjacent to one or more urban areas as being
located in the urban area to which the greatest number of workers in
the county commute. Also, section 1886(d)(10) of the Act established
the MGCRB to permit hospitals that are disadvantaged by their
geographic classification to obtain a more appropriate classification
to the area with which they have the most economic interaction.
In the August 1, 2000 interim final rule with comment period (65 FR
47029), we implemented section 401(a) of Public Law 106-113. Section
401(a) of Public Law 106-113, which amended section 1886(d)(8) by
adding a new paragraph (E), directs the Secretary to treat any
subsection (d) hospital located in an urban area as being located in
the rural area of the State in which the hospital is located if the
hospital files an application (in the form and manner determined by the
Secretary) and meets one of the following criteria:
The hospital is located in a rural census tract of an MSA
(as determined under the most recent modification of the Goldsmith
Modification, originally published in the Federal Register on February
27, 1992 (57 FR 6725));
The hospital is located in an area designated by any law
or regulation of the State as a rural area (or is designated by the
State as a rural hospital);
The hospital would qualify as a rural referral center, or
as an SCH if the hospital were located in a rural area; or
The hospital meets any other criteria specified by the
Secretary.
The statutory effective date of this provision is January 1, 2000.
In the August 1, 2000 interim final rule with comment period, we
provided a detailed discussion of the development of the Goldsmith
Modifications (65 FR 47029). The Goldsmith Modification evolved from an
outreach grant program sponsored by the Office of Rural Health Policy
of the Health Resources and Services Administration (HRSA) in order to
establish an operational definition of rural populations lacking easy
geographic access to health services. Using 1980 census data, Dr.
Harold F. Goldsmith and his associates created a methodology for
identification of rural census tracts that were located within a large
metropolitan county of at least 1,225 miles but were so isolated from
the metropolitan core by distance or physical features so as to be more
rural than urban in character. We utilize data based on 1990 census
data, reflecting the most recent Goldsmith modification.
We also included Appendix A of that interim final rule with comment
period a listing of the identified urban counties with census tracts
that may qualify as rural under the most recent Goldsmith Modification
(January 1, 2000). The amendments made by section 401 of Public Law
106-113 enable a hospital located in one of the areas listed in
Appendix A of the August 1, 2000 interim final rule with comment period
to be treated as if it were situated in the rural area of the State in
which it is located.
Additionally, section 401(a) of Public Law 106-113 includes
hospitals ``* * * located in an area designated by any law or
regulation of such State as a rural area (or is designated by such
State as a rural hospital).'' Since the concept of State
``designation'' referred to in the parenthetical clause was not
explicit enough to provide a clear-cut rule for purposes of
implementation, we required that a hospital's designation as rural be
in the form of either State law or regulation if it is the basis for a
hospital's request for urban to rural reclassification. We believe this
will help ensure that the provision is implemented consistently among
States.
Finally, a hospital also may seek to qualify for reclassification
premised on the fact that, had it been located in a rural area, it
would have qualified as a rural referral center or as an SCH. The
hospital would need to satisfy the criteria set forth in section
1886(d)(5)(C) of the Act (as implemented in regulations at Sec. 412.96)
as a rural referral center, or the criteria set forth in section
1886(d)(5)(D) of the Act (as implemented in regulations at Sec. 412.92)
as an SCH.
Although the statute authorizes the Secretary to specify further
qualifying criteria for a section 401 reclassification, we did not
believe that additional criteria were warranted at the time the August
1, 2002 interim final rule was published. However, we invited comment
specifically on whether the criteria in the interim final rule are
sufficient at this time, and if not, what additional criteria should be
incorporated.
A hospital that is reclassified as rural under section
1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-
113, is treated as rural for all purposes of payment under the Medicare
inpatient hospital prospective payment system (section 1886(d) of the
Act), including standardized amount (Secs. 412.60 et seq.), wage index
(Sec. 412.63), and the DSH payment adjustment calculations
(Sec. 412.106) as of the effective date of the reclassification.
Comment: One commenter addressed policies discussed in the August
1, 2000 interim final rule with comment period. Other commenters
addressed our policy to not permit hospitals that are redesignated as
rural under section 1886(d)(8)(E) of the Act to be eligible for
subsequent reclassifications by the MGCRB.
Response: These policies were addressed in the May 5, 2000 proposed
rule (65 FR 26308) and the August 1, 2000 final rule (65 FR 47087)
implementing the updates and policy changes to the prospective payment
system for FY 2001. We responded to comments on the May 5, 2000
proposed rule in the August 1, 2000 final rule. Because we addressed
these concerns in that final rule, we are not readdressing those
comments in this final rule.
Comment: An association of physicians commented that the interim
final rule with comment period stated that a hospital that is
reclassified as rural under this provision must be treated as rural for
all purposes of payment under the Medicare inpatient hospital
prospective payment system, including standardized amount, wage index,
and the DSH payment adjustment. However, the commenter pointed out,
graduate medical education is not listed. The commenter urged that
these hospitals also be considered rural for purposes of graduate
medical education.
Response: Section 1886(d)(8)(E) of the Act provides that affected
hospitals are considered rural for purposes of section 1886(d).
Therefore, these reclassifications affect payments to a hospital under
the IME adjustment, which are made under section 1886(d)(5)(B) of the
Act, but not payments for direct GME, which are made under section
1886(h) of the Act.
[[Page 39886]]
2. Conforming Changes under Section 401(b) of Public Law 106-113
Section 401(b) of Public Law 106-113 sets forth conforming
statutory changes relating to urban to rural reclassifications under
section 401(a) of Public Law 106-113:
Section 401(b)(1) provided that if a hospital is being
treated as being located in a rural area under section 1886(d)(8)(E) of
the Act (for purposes of section 1886(d) of the Act), the hospital will
also be treated under section 1833(t) of the Act as being located in a
rural area. This provision was addressed in the final rule for the
hospital inpatient prospective payment system published in the Federal
Register on August 1, 2000 (65 FR 47087).
Section 401(b)(2) amended section 1820(c)(2)(B)(i) of the
Act by extending the reclassification provisions of section 401(a) to
the CAH program. A hospital that otherwise would have fulfilled the
requirements for designation as a CAH had it been located in a rural
area is now eligible for consideration as a CAH if it is treated as
being located in a rural area under section 1886(d)(8)(E) of the Act,
as added by section 401(a) of Public Law 106-113. (A list of certain
existing hospitals that were identified as being located in Goldsmith
areas was included in Appendix B of the August 1, 2000 interim final
rule with comment period.) A more detailed discussion of the effect on
the CAH program of this provision, as well as additional amendments to
section 1820(c)(2)(B)(i) of the Act included in Public Law 106-113, is
provided in section VI.B. of this preamble.
3. Application Procedures
The statute provides that a hospital seeking reclassification from
urban to rural under section 1886(d)(8)(E) of the Act must submit an
application ``in a form and manner determined by the Secretary.'' In
the August 1, 2000 interim final rule with comment period, we set forth
procedures and requirements for the application for rural
reclassification, including application submittal requirements, the
filing and effective dates for the application, the procedures for
withdrawal of applications, and cancellation of rural reclassification;
and the qualifications through the Goldsmith Modification Criteria, by
State designation and qualifications as a rural referral center or as
an SCH. (See 65 FR 47030 through 47031 for a full discussion of these
procedures and requirements.) As of early July 2001, 19 hospitals had
taken advantage of this provision.
4. Changes in the Regulations
In the August 1, 2000 interim final rule with comment period, we
added a new Sec. 412.103 to incorporate the provisions on the urban to
rural reclassification options set forth in section 1886(d)(8)(E) of
the Act, as added by section 401(a) of Public Law 106-113, and the
application procedures for requesting reclassification.
A formula for transition payments to hospitals located in an area
that has undergone geographic reclassification from urban to rural is
set forth in section 1886(d)(8)(A) of the Act and implemented in
regulations at Secs. 412.90 and 412.102. In the interim final rule with
comment period, we revised existing Secs. 412.63(b)(1) and 412.90(e)
and the title of Sec. 412.102 to clarify the distinction between
hospital reclassification from urban to rural and the geographic
reclassification (or redesignation) of an urban area to rural.
In addition, we revised Sec. 485.610 by redesignating paragraph
(b)(4) as paragraph (b)(5) and adding a new paragraph (b)(4) to reflect
the conforming provision of section 401(b)(2) of Public Law 106-113.
We did not receive any comments on these changes in the regulations
in the interim final rule with comment period and, therefore, are
adopting them as final.
G. Medicare Geographic Classification Review Board (MGCRB) (New
Sec. 412.235 and Existing Secs. 412.256, 412.273, 412.274(b), and
412.276)
With the creation of the MGCRB, beginning in FY 1991, under section
1886(d)(10) of the Act, hospitals could request reclassification from
one geographic location to another for the purpose of using the other
area's standardized amount for inpatient operating costs or the wage
index value, or both (September 6, 1990 interim final rule with comment
period (55 FR 36754), June 4, 1991 final rule with comment period (56
FR 25458), and June 4, 1992 proposed rule (57 FR 23631)). Implementing
regulations in Subpart L of Part 412 (Secs. 412.230 et seq.) set forth
criteria and conditions for redesignations from rural to urban, rural
to rural, or from an urban area to another urban area with special
rules for SCHs and rural referral centers.
As discussed in section III.F. of this final rule, section 304 of
Public Law 106-554 contained several provisions related to the wage
index and reclassification decisions made by the MGCRB. In summary,
section 304 first establishes that hospital reclassification decisions
by the MGCRB for wage index purposes are effective for 3 years,
beginning with reclassifications for FY 2001. Second, it provides that
the MGCRB must use the 3 most recent years of average hourly wage data
in evaluating a hospital's reclassification application for FY 2003 and
subsequent years. Third, it provides that an appropriate statewide
entity may apply to have all of the geographic areas in a State treated
as a single geographic area for purposes of computing and applying the
wage index, for reclassifications beginning in FY 2003. In the May 4,
2001 proposed rule, we presented a discussion of how we proposed to
implement these three provisions. (Section III.F. of this preamble
discusses the application of these policy changes to the development of
the final FY 2002 and later wage indexes based on hospital
reclassification under the provisions of section 304 of Public Law 106-
554.)
1. Three-Year Reclassifications for Wage Index Purposes
Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D)
of the Act by adding clause (v), which provides that, if a hospital is
approved for reclassification by the MGCRB for purposes of the wage
index, the reclassification is effective for 3 years. The amendment
made by section 304(a) is effective for reclassifications for FY 2001
and subsequent years. In addition, the legislation specifies that the
Secretary must establish a mechanism under which a hospital may elect
to terminate such reclassification during the 3-year period.
Consistent with new section 1886(d)(10)(D)(v) of the Act, in the
May 4 proposed rule, we proposed to revise Sec. 412.274(b) to provide
under new paragraph (b)(2) that any hospital that is reclassified for a
particular fiscal year for purposes of receiving the wage index value
of another area would receive that reclassification for 3 years
beginning with discharges occurring on the first day (October 1) of the
second Federal fiscal year in which a hospital files a complete
application. This 3-year reclassification would remain in effect unless
the hospital terminates the reclassification under revised procedures
that we proposed to establish under new proposed Sec. 412.273(b). The
provision would apply to hospitals that are reclassified for purposes
of the wage index only, as well as those that are reclassified for both
the wage index and the standardized amount. However, in the latter
case, only the wage index reclassification would be extended for 2
additional
[[Page 39887]]
years beyond the 1 year provided for in the existing regulations (3
years total). Hospitals seeking reclassification for purposes of the
standardized amount must continue to reapply to the MGCRB on an annual
basis.
a. Special Rule for a Hospital that was Reclassified for FY 2001 and FY
2002 to Different Areas
Because the 3-year effect of the amendment made by section 304(a)
of Public Law 106-554 is applicable to reclassifications for FY 2001
(which had already taken place prior to the date of enactment of
section 304(a) (December 21, 2000)), and because the application
process for reclassifications for FY 2002 had already been completed by
the date of enactment, we are establishing special procedures for
hospitals that are reclassified for purposes of the wage index to one
area for FY 2001, and are reclassified for purposes of the wage index
or the standardized amount to another area for FY 2002. We are deeming
such a hospital to be reclassified to the area for which it applied for
FY 2002, unless the hospital elects to receive the wage index
reclassification it was granted for FY 2001. Consistent with our
procedures for withdrawing an application for reclassification
(Sec. 412.273), we allowed a hospital that wished to receive the
reclassification it was granted for FY 2001 to withdraw its FY 2002
application by making a written request to the MGCRB within 45 days of
the publication date of the proposed rule (that is, by June 18, 2001).
Again, only the wage index reclassification is extended for 2
additional years (3 years total). Hospitals seeking reclassification
for purposes of the standardized amount must continue to reapply to the
MGCRB on an annual basis.
(We note that, effective May 21, 2001, the new location and mailing
address of the MGCRB and the Provider Reimbursement Review Board (PRRB)
is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670.
Please specify whether the mail is intended for the MGCRB or the PRRB.)
b. Overlapping Reclassifications Are Not Permitted
Under the broad authority delegated to the Secretary by section
1886(d)(10) of the Act, in the May 4 proposed rule, we proposed that a
hospital that is reclassified to an area for purposes of the wage index
may not extend the 3-year effect of the reclassification under section
304(a) of Public Law 106-554 by subsequently applying for
reclassification to the same area for purposes of the wage index for a
fiscal year that would be within the 3-year period. For example, if a
hospital is reclassified for purposes of the wage index to Area A for
FY 2002, is approved to receive Area A's wage index for 3 years (FYs
2002, 2003, and 2004), and reapplies to be reclassified to Area A for
FYs 2003, 2004, and 2005 (3 years) for purposes of the wage index, the
hospital would not be permitted to receive Area A's wage index for FY
2005 as a result of the reapplication. Instead, we proposed that if the
hospital wishes to extend the FY 2002 3-year reclassification for
fiscal years beyond FY 2004, it would have to apply for
reclassification for FY 2005.
We believe new section 1886(d)(10)(D)(v) of the Act replaces the
current annual wage index reclassification cycle with a 3-year
reclassification cycle. We believe this policy was intended to provide
consistency and predictability in hospital reclassification and wage
index data, as well as to alleviate the year-to-year fluctuations in
the ability of some hospitals to qualify for reclassification. We do
not believe it was intended to be used to extend reclassifications for
which hospitals otherwise would not be eligible (by reapplying during
the second year of a 3-year reclassification because a hospital fears
it may not be eligible for reclassification after its current 3-year
reclassification expires).
c. Withdrawals of Applications and Terminations of Approved
Reclassifications
(1) General
Under Sec. 412.273(a), a hospital, or group of hospitals, may
withdraw its application for reclassification at any time before the
MGCRB issues its decision or, if after the MGCRB issues its decision,
within 45 days of publication of our annual notice of proposed
rulemaking concerning changes to the inpatient hospital prospective
payment system and proposed payment rates for the fiscal year for which
the application was filed. In the May 4 proposed rule, we proposed that
the withdrawal procedures and the applicable timeframes in the existing
regulations would apply to hospitals that would receive 3-year
reclassification for wage index purposes. For example, if a hospital
applied for reclassification to Area A for purposes of the wage index
for FY 2002, but wished to withdraw its application, it must have done
so prior to the MGCRB issuing a decision on its application or, if the
MGCRB issued such a decision, within 45 days of the publication date of
the proposed rule (that is, by June 18, 2001). Such a withdrawal, if
effective, means that the hospital would not be reclassified to Area A
for purposes of the wage index for FY 2002 (and would not receive
continued reclassification for FYs 2003 and 2004), unless the hospital
subsequently cancels its withdrawal (as discussed below). In other
words, a withdrawal, if accepted, prevents a reclassification from ever
becoming effective.
On the other hand, a reclassification decision that is terminated
upon the request of the hospital has partial effect. Section
1886(d)(10)(D)(v) of the Act, as added by section 304(a) of Public Law
106-554, provides that a reclassification for purposes of the wage
index is effective for 3 years ``except that the Secretary shall
establish procedures under which a . . . hospital may elect to
terminate such reclassification before the end of such period.''
Consistent with section 1886(d)(10)(D)(v) of the Act, we proposed to
allow a hospital to terminate its approved 3-year reclassification for
1 or 2 years of the 3-year effective period (Sec. 412.273(b)). This is
a separate action from a reclassification withdrawal, which occurs
following the initial decision by the MGCRB. A termination would occur
during subsequent years. For example, a hospital that has been
reclassified for purposes of the wage index for FY 2001 is also
reclassified for FYs 2002 and 2003 (3 years). Such a hospital could
terminate its approved reclassification so that the reclassification is
effective only for FY 2001, or only for FYs 2001 and 2002. Consistent
with the prospective nature of reclassifications, we proposed to not
permit a hospital to terminate its approved 3-year reclassification for
part of a fiscal year. A termination would be effective for the next
fiscal year. In order to terminate an approved 3-year reclassification,
we would require the hospital to notify the MGCRB in writing within 45
days of the publication date of the annual proposed rule for changes to
the inpatient hospital prospective payment system. A termination,
unless subsequently cancelled (as discussed below), is effective for
the balance of the 3-year period.
We established a special procedural rule for handling FY 2001
reclassifications. As noted above, the amendments made by section
304(a) of Public Law 106-554 are effective for reclassifications for
FYs 2001 and beyond, and reclassification decisions for FY 2001 had
already been implemented prior to the date of enactment of section
304(a). We deemed those hospitals that were reclassified for
[[Page 39888]]
FY 2001 to be reclassified for FYs 2002 and 2003. Therefore, if a
deemed hospital that was reclassified for purposes of the wage index
for FY 2001 wished to terminate its reclassification for FY 2002 and FY
2003, the hospital had to notify the MGCRB in writing by June 18, 2001
(that is, within 45 days after the publication of the proposed rule).
(2) Cancellation of a Withdrawal of Application or a Termination of an
Approved Reclassification
In the May 4 proposed rule, we proposed that if a hospital elects
to withdraw its 3-year reclassification application after the MGCRB has
issued its decision, it may cancel its withdrawal in a subsequent
fiscal year and request the MGCRB to reinstate its reclassification for
the remaining fiscal years of the 3-year reclassification period. (This
proposal was consistent with our proposal that 3-year reclassification
periods may not overlap, as discussed in section IV.G.1.b. of this
preamble.) Alternatively, a hospital may apply for reclassification to
a different area (that is, an area different from the one to which it
was originally reclassified), and if successful, the reclassification
effect would be for 3 years.
Similarly, and for the same reasons, we proposed that if a hospital
elects to terminate its accepted 3-year reclassification prior to the
second or third year of that reclassification, it may cancel that
termination and have its original reclassification reinstated for the
duration of the original 3-year period. Alternatively, a hospital could
apply for reclassification to a different area after terminating a
prior 3-year reclassification and receive a new 3-year period of
reclassification.
Example 1: Hospital A files an application and the MGCRB issues
a decision to reclassify it to Area B for purposes of wage index for
FY 2002 through FY 2004 (3 years). Within 45 days after the
publication of the proposed rule, Hospital A withdraws its
application. Within the time for applying for a FY 2003
reclassification, Hospital A cancels its withdrawal for
classification to Area B. Its reclassification to Area B is
reinstated, but only for FYs 2003 and 2004.
Example 2: Hospital B files an application for reclassification
for wage index purposes for FY 2002 through FY 2004 and the MGCRB
issues a decision for reclassification to Area C. Within 45 days
after publication of the proposed rule, Hospital B withdraws its
application. Hospital B does not cancel its withdrawal of the
application. Hospital B timely applies and is reclassified to Area D
for 3 years, beginning with FY 2003. In this case, the
reclassification to Area D would be for FYs 2003 through 2005.
Example 3: Hospital C is reclassified to Area A for purposes of
the wage index for FY 2002, and terminates its 3-year
reclassification effective for FYs 2003 and 2004. Within the
timeframe for applying for FY 2004 reclassification, Hospital C
cancels its termination. Its reclassification to Area A would be
reinstated for FY 2004 only.
Example 4: Hospital D has the same circumstances as Hospital C
in Example 3, except that instead of canceling its termination,
Hospital D applies and is reclassified to Area B for FY 2004. In
this case, the reclassification would be for FYs 2004 through 2006.
d. Special Rules for Group Reclassifications
Section 412.232 discusses situations where all hospitals in a rural
county are seeking urban redesignation, and Sec. 412.234 discusses
criteria where all hospitals in an urban county are seeking
redesignation to another urban county. In these cases, hospitals submit
an application as a group, and all hospitals in the county must be a
party to the application. The reclassification is effective both for
purposes of the wage index and the standardized amount of the area to
which the hospitals are reclassified.
Section 304(a) of Public Law 106-554 does not specifically address
the group reclassification situations under Secs. 412.232 and 412.234.
However, we believe that, in the case of hospitals reclassified under
these group reclassification procedures, it would be appropriate to
extend the 3-year reclassification provision to these situations for
the wage index only. In order to be reclassified for the standardized
amount during the second and third years of a 3-year reclassification
for the wage index, the hospitals located in these counties would have
to reapply on an annual basis to the MGCRB either as a group or as
individual hospitals and meet the criteria outlined in Sec. 412.232,
Sec. 412.234, or Sec. 412.230, as appropriate.
Hospitals that are part of a group reclassification would be able
to terminate their 3-year wage index reclassifications in the same
manner as described above. If one hospital within the group elects to
terminate its 3-year wage index reclassification, the reclassification
of other hospitals in the group would be unaffected. The same rules for
withdrawing from a group reclassification that are in effect now would
continue. That is, all of the hospitals that are party to a group
reclassification application must consent for a withdrawal to be
approved.
Under section 152(b) of Public Law 106-113, hospitals in certain
counties were deemed to be located in specified areas for purposes of
payment under the hospital inpatient prospective payment system, for
discharges occurring on or after October 1, 2000. For payment purposes,
these hospitals are to be treated as though they were reclassified for
purposes of both the standardized amount and the wage index. Section
152(b) also requires that these reclassifications be treated for FY
2001 as though they are reclassification decisions by the MGCRB. For
purposes of applying the 3-year extension of wage index
reclassifications, we proposed to extend section 1886(d)(10)(D)(v) to
hospitals reclassified under section 152(b) of Public Law 106-113.
These hospitals also would have to apply for the standardized amount on
an annual basis to the MGCRB.
e. Administrator Authority to Cancel Inappropriate Reclassification
Decisions
In the proposed rule we indicated that, under the provisions of
Sec. 412.278(g), the Administrator has the authority to review an
inappropriate reclassification decision made by the MGCRB, as
discovered by either the hospital or CMS, including 3-year
reclassifications in the second and third years. The statement that
this authority extended to the second and third years of 3-year
reclassification was in error. Under the statute and our regulations,
reclassification decisions are unreviewable once they become final.
This principle applies to 3-year reclassification decisions. Once such
a decision becomes final, it is unreviewable thereafter.
Comment: Several commenters expressed concern that we proposed that
a hospital that is reclassified to an area for purposes of the wage
index may not extend the 3-year effect of the reclassification under
section 304(a) of Public Law 106-554, by subsequently applying for
reclassification to the same area for purposes of the wage index for a
fiscal year that would be within the 3-year period. These commenters
argued that there is nothing in the statutory language that prohibits
hospitals that are already approved for 3-year reclassifications from
reapplying within that 3-year period to extend their reclassifications
into future years. These commenters also pointed out that extending
their wage index reclassifications in this way allows them to make
budgetary commitments further into the future and fosters a more stable
operating environment for their hospitals.
Response: Under section 1886(d)(10) of the Act, the Secretary has
broad authority to establish policies and
[[Page 39889]]
criteria with respect to the evaluation and approval of applications
for reclassification. As indicated in the proposed rule, we believe
that new section 1886(d)(10)(D)(v) of the Act, as added by section
304(a) of Public Law 106-554, replaces the annual reclassification
cycle with a 3-year reclassification cycle. We believe that, if a
hospital is already reclassified to a given geographic area for a 3-
year period, it is appropriate to avoid expending resources to evaluate
an application for reclassification to that same area for the second
and third years of the 3-year period. Thus, if a hospital is already
reclassified for a given fiscal year, and submits an application for
reclassification to the same area for the same year, that application
will not be approved. We are adding language to Sec. 412.230(a)(5)(v)
in this final rule to specify that an application for reclassification
will not be approved under these circumstances.
Comment: One commenter supported our proposal to reclassify a
hospital based on its FY 2002 approval unless the hospital notified the
MGCRB otherwise by June 18, 2001. This commenter questioned whether or
not hospitals would have this same option in future years. In other
words, if a hospital successfully sought reclassification to a
different area for FY 2003 and then withdrew that reclassification,
would that hospital have the option to fall back on the FY 2002
reclassification, or would it then not be reclassified.
Response: We appreciate the commenter's support of our proposal on
this issue. This was specifically put in place because the new 3-year
reclassification policy was not enacted until well after the
reclassification process for FY 2002 was underway. Therefore, some
hospitals may have sought reclassification to a different area or for a
different purpose than they did for FY 2001, and the option to carry
forward a FY 2001 wage index reclassification for 3 years may have
changed their decisions.
This policy applies in future years as well. For example, a
hospital that successfully seeks reclassification for the wage index
for FY 2004 to Area A, then successfully seeks reclassification for FY
2005 for the wage index to Area B, has the option to withdraw its FY
2005 decision, thereby reinstating its FY 2004 decision. However, if
the hospital successfully withdraws its FY 2005 decision, the hospital
cannot return to its FY 2005 decision without reapplying at a later
date.
Comment: Several commenters expressed uncertainty about the timing
of the extension of the wage index reclassification for 3 years. Some
hospitals had successfully applied for FY 2001 as well as FY 2002 to
the same area for the wage index, and it was not clear to these
hospitals whether their wage index reclassifications were effective
through FY 2003 or through FY 2004.
Response: As noted above, section 304(a) provides for 3-year wage
index reclassifications effective with FY 2001 reclassifications. In
the case of hospitals reclassified to the same area for both FY 2001
and FY 2002, because hospitals had already submitted their FY 2002
applications prior to enactment of Public Law 106-554, and the MGCRB
had already issued its decision on these applications prior to
publication of the May 4 proposed rule, we will consider FY 2002 to be
the first year of the 3-year reclassification for these hospitals.
Therefore, the reclassification period will extend through FY 2004. If
a hospital was approved for FY 2001 for a wage index reclassification,
but was unsuccessful in seeking a wage index reclassification for FY
2002, then its wage index reclassification would be effective for FY
2001, FY 2002, and FY 2003, and the hospital would have to reapply to
seek reclassification for FY 2004.
Comment: One commenter supported our proposal that a hospital could
cancel its withdrawal of an approved reclassification for the wage
index in a future year in order to reinstate its original MGCRB
approval.
Response: We appreciate the commenter's support of our proposal
that hospitals reclassified for the wage index that then withdraw that
approval have the ability to cancel the withdrawal, in effect
reinstating the hospital's original reclassification approval for the
wage index. We provided this option so that a hospital that later
discovers that the withdrawal of its approved wage index
reclassification was disadvantageous would have the ability to
reinstate its MGCRB approval for the wage index for the remaining years
in the 3-year term. However, a hospital is eligible to revert to its
most recent MGCRB approval only.
In addition, the same process applies to cancellations of a
withdrawal or termination as applies to requests for withdrawals and
terminations. A hospital must request a cancellation of its withdrawal
or termination within the 45-day period after the proposed rule is
published, and that cancellation will become effective for the
following Federal fiscal year.
Comment: Several commenters supported our proposal to extend the 3-
year reclassification provision for the wage index to those hospitals
that were reclassified for FY 2001 under section 152(b) of Public Law
106-113. While these hospitals did not successfully apply for
reclassification through the MGCRB, they were effectively
``reclassified'' by this legislation, and the commenters believed that
it would be correct to extend the 3-year wage index reclassification to
this group of hospitals.
Response: We appreciate the commenters' support of our proposal.
Section 152(b) of Public Law 106-113 required that the assignment of
these hospitals to alternative geographic areas should be treated as if
they were decisions of the MGCRB. As a result, these hospitals will be
reclassified for the wage index to their designated areas for FY 2002
and FY 2003. They will be required to apply for reclassification to the
MGCRB for FY 2004 if they wish to retain this reclassification for
subsequent years.
2. Three-Year Average Hourly Wages
Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D)
of the Act by adding clause (vi) which provides that the MGCRB must use
the average of the 3 most recent years of hourly wage data for the
hospital when evaluating a hospital's request for reclassification.
Specifically, the MGCRB must base its evaluation on an average of the
average hourly wage for the most recent years for the hospital seeking
reclassification and the area to which the hospital seeks to
reclassify. This provision is effective for reclassifications for FY
2003 and subsequent years. (Section III.F. of this preamble discusses
the development and application of the hospital's 3-year average hourly
wage data (Table 2 in the Addendum to this final rule) that the MGCRB
will use to evaluate hospitals' applications for reclassifications for
FY 2003; and the MSA and statewide rural 3-year average hourly wage
data (Tables 3A and 3B in the Addendum to this final rule) for hospital
reclassification applications for FY 2003.)
In the May 4, 2001 proposed rule, we proposed to revise
Secs. 412.230(e)(2) and 412.232(d)(2) to incorporate the provisions of
section 1886(d)(10)(D)(vi) of the Act as added by section 304(a) of
Public Law 106-554. Specifically, we provided that, for redesignations
effective beginning FY 2003, for hospital-specific data, the hospital
must provide a 3-year average of its average hourly wages using data
from our hospital wage survey used to construct
[[Page 39890]]
the wage index in effect for prospective payment purposes. For data for
other hospitals, we proposed to require hospitals to provide a 3-year
average of the average hourly wage in the area in which the hospital is
located and a 3-year average of the average hourly wage in the area to
which the hospital seeks reclassification. The wage data would be taken
from the CMS hospital wage survey used to construct the wage index for
prospective payment purposes, as published in Tables 2, 3A, and 3B of
this final rule (unless those data are subsequently changed by CMS).
The 3-year averages are calculated by dividing the sum of the dollars
(adjusted to a common reporting period using the method described in
section III. of this final rule) across all 3 years, by the sum of the
hours.
Comment: Several commenters responded positively to our proposal to
use a 3-year average of the most recent 3 years of average hourly wages
based on data from our hospital wage survey used to construct the wage
index when evaluating a hospital's request for reclassification. Under
the proposal, if data does not exist for all 3 years, the available
data within the 3-year period will be used to construct the average.
While it was clear to these commenters that these data will be used
to construct the average hourly wage for a hospital applying for
reclassification, they noted it was not clear to them whether the 3-
year average would also be used for the area in which that hospital is
physically located as well as the area to which that hospital seeks
reclassification.
Response: We appreciate the commenters' support of our proposal to
calculate the 3-year average hourly wage based on the data available
during the applicable 3-year period, even if a hospital does not have
data in all 3 years.
As noted above, the MGCRB will evaluate applications using the 3-
year average hourly wages for hospitals and geographic areas as
published in Tables 2, 3A, and 3B of this final rule (unless those data
are subsequently changed by CMS).
Comment: One commenter requested that in cases of a change in
ownership, a hospital be permitted the option of excluding prior years'
wage data submitted by a previous owner for the purpose of calculating
the average of the average hourly wages in order to qualify for
reclassification. As a result, the average of the average hourly wages
would be based on current and prior year data submitted by the new
owner only.
Response: We believe we should treat these cases in a manner
consistent with how we treat hospitals whose ownership has changed for
other Medicare payment purposes. That is, where a hospital has simply
changed ownership and the new owners have acquired the assets and
liabilities of the previous owners, all of the applicable wage data
associated with that hospital are included in the calculation of its 3-
year average hourly wage. On the other hand, in the case of a new
hospital, where there is no legal obligation to the operations of a
predecessor hospital, the wage data associated with the previous
hospital's provider number would not be used in calculating the new
hospital's 3-year average hourly wage.
3. Statewide Wage Index
As stated earlier, section 304(b) of Public Law 106-554 provides
for a process under which an appropriate statewide entity may apply to
have all the geographic areas in the State treated as a single
geographic area for purposes of computing and applying the area wage
index for reclassifications beginning in FY 2003.
Section 304 does not indicate the duration of the application of
these statewide wage indexes. However, it should be noted that the
statutory language does refer to these applications as
reclassifications. In the May 4, 2001 proposed rule, we proposed that
these statewide wage index applications be processed similar to MGCRB
applications, with the same effective dates of the decisions and the
withdrawal and termination process. Therefore, similar to wage index
reclassification decisions under section 1886(d)(10)(D)(v) of the Act
as added by section 304(a) of Public Law 106-554, the statewide wage
index reclassification would be effective for a total of 3 years. The
same deadlines and timetable applicable to MGCRB reclassification
applications would apply for statewide wage index applications.
We proposed to establish a new Sec. 412.235 to include the
requirements for statewide wage indexes. We proposed to apply the
following criteria to determine whether hospitals would be approved for
a statewide geographic wage index reclassification (Sec. 412.235(a)):
There must be unanimous support for a statewide wage index
among hospitals in the State in which the statewide wage index would be
applied. We would require a signed affidavit on behalf of all the
hospitals in the State of this support as part of the application for
reclassification.
All hospitals in the State must apply through a signed
single application for the statewide wage index in order for the
application to be considered by the MGCRB. We believe this is necessary
to ensure that every hospital in the State is included in the
application, since the payment of every hospital would be affected by
the statewide wage index.
There must be unanimous support for the termination or
withdrawal of a statewide wage index among hospitals in the State in
which the statewide wage index would be applied. We would require a
signed affidavit for this agreement.
All hospitals in the State waive their rights to any wage
index that they would otherwise receive absent the statewide wage
index, including a wage index that any of the hospitals might have
received through individual or group geographic reclassification under
Sec. 412.273(a).
An individual hospital within the State may receive a wage index
that could be higher or lower under the statewide wage index
reclassification in comparison to its wage index otherwise
(Sec. 412.235(b)). Specifically, hospitals must be aware that there may
be a reduction in the wage index as a result of participation on a
statewide basis.
In addition, we proposed to consider statewide wage index
applications under the same process we use for hospital
reclassification applications, including the effective dates of the
MGCRB decision and the withdrawal and termination process
(Sec. 412.235(c)). We proposed that applications for the statewide wage
index would be effective for 3 years beginning with discharges
occurring on the first day (October 1) of the second Federal fiscal
year following the Federal fiscal year in which the hospitals file a
complete application unless all of the participating hospitals withdraw
their application or terminate their approved statewide wage index
reclassification earlier, as discussed below. Once approved by the
MGCRB, an application for a statewide wage index can only be withdrawn
or terminated as a result of a signed affidavit on behalf of all the
hospitals in the State indicating their request that the statewide
reclassification be withdrawn or terminated. A request for withdrawal
or termination must be submitted within 45 days of the publication of
the annual proposed rule for the inpatient hospital prospective payment
system announcing the reclassification. New hospitals that open prior
to the September 1 deadline for submitting an application for a
statewide wage index, but after a group
[[Page 39891]]
application has been submitted, would be required to agree to the
statewide wage index in order for the group application to remain
viable. New hospitals that open after the deadline for submitting an
application would receive the statewide wage index. The agreement of
new hospitals would also be required in order to withdraw or terminate
a statewide wage index reclassification. The rules discussed under
section IV.G.1.c. of this preamble for withdrawals of applications and
terminations of approved 3-year wage index reclassification decisions
would apply to decisions regarding statewide wage index
reclassifications.
Comment: Several commenters believed that Washington, DC should be
recognized as a State for purposes of this statewide wage index
reclassification policy. However, they were concerned that, while such
a recognition may benefit hospitals located in Washington, DC, it may
not benefit hospitals that are currently located outside of Washington,
DC but within the Washington, D.C.-MD-VA-WV MSA. As a result, while
these commenters believed that Washington, DC should be recognized as a
State for this purpose, they also requested guidance about how the
remainder of the hospitals in the current MSA would be treated.
One commenter did not believe that Washington, DC should be
considered a State for this purpose. However, this commenter also
stated that, should we decide that Washington, DC could be considered a
State for this purpose, we should configure the criteria such that none
of the hospitals that are currently located in the Washington, D.C.-MD-
VA-WV MSA would be harmed.
Response: Section 304(b) of Public Law 106-554 directs the
Secretary to establish a process ``under which an appropriate statewide
entity may apply to have all the geographic areas in a State treated as
a single geographic area for purposes of computing and applying the
area wage index under section 1886(d)(3)(E) of [the Social Security]
Act. * * *'' Most States encompass multiple labor market areas (urban
MSAs and rural areas) with differing wage indexes, and we believe that
the intent of section 304(b) is to offer hospitals within a State the
opportunity to eliminate the disparate wage indexes resulting from
separate urban and rural labor market areas within the State. However,
hospitals in Washington, DC are not subject to disparate wage indexes.
Washington, DC is part of a larger labor market area where all the
hospitals receive the wage index for that labor market area (subject to
MGCRB reclassifications). Put another way, Washington, DC is already
``treated as a single geographic area'' for purposes of the hospital
wage index.
If we treated Washington, DC as a separate distinct labor market
area and applied the usual wage index methodology, Washington, DC
hospitals might reap a significant windfall and the hospitals remaining
in the MSA might be disadvantaged. Given the intended purpose of
section 304(b), we believe that such results would be inappropriate. We
believe that Congress did not intend for section 304(b) to address the
type of situation presented by Washington, DC.
As indicated above, section 304(b) permits a State to be treated as
a single geographic area ``for purposes of computing and applying the
area wage index under section 1886(d)(3)(E) of [the] Act.'' Section
304(b) does not specify how to compute and apply the wage index for
statewide geographic areas. Under section 1886(d)(3)(E) of the Act, the
Secretary has broad authority to develop and apply the methodology for
determining the wage index for labor market areas, and section 304(b)
did not limit the agency's authority. Thus, even if Washington, DC is a
State for purposes of section 304(b), the Secretary has broad authority
under section 1886(d)(3)(E) to determine the wage index for all
affected hospitals. Given the purpose of section 304, and to avoid
conferring an inappropriate and unintended windfall (or disadvantage)
to hospitals, we are providing (pursuant to our broad authority under
section 1886(d)(3)(E) of the Act) that, even if Washington, DC is a
State for purposes of section 304(b) of Public Law 106-554, the wage
index applicable to the Washington, DC ``statewide'' geographic area
would be the same wage index that would apply to the Washington, DC-MD-
VA-WV MSA as a whole (which would be calculated by including
Washington, DC hospitals, in accordance with all applicable rules).
H. Payment for Direct Costs of Graduate Medical Education (Sec. 413.86)
1. Background
Under section 1886(h) of the Act, Medicare pays hospitals for the
direct costs of graduate medical education (GME). The payments are
based in part on the number of residents trained by the hospital.
Section 1886(h) of the Act, as amended by section 4623 of Public Law
105-33, caps the number of residents that hospitals may count for
direct GME.
Section 1886(h)(2) of the Act, as amended by section 9202 of the
Consolidated Omnibus Reconciliation Act (COBRA) of 1985 (Public Law 99-
272), and implemented in regulations at Sec. 413.86(e), establishes a
methodology for determining payments to hospitals for the costs of
approved GME programs. Section 1886(h)(2) of the Act, as amended by
COBRA, sets forth a payment methodology for the determination of a
hospital-specific, base-period per resident amount (PRA) that is
calculated by dividing a hospital's allowable costs of GME for a base
period by its number of residents in the base period. The base period
is, for most hospitals, the hospital's cost reporting period beginning
in FY 1984 (that is, the period of October 1, 1983 through September
30, 1984). The PRA is multiplied by the number of FTE residents working
in all areas of the hospital complex (or nonhospital sites, when
applicable), and the hospital's Medicare share of total inpatient days
to determine Medicare's direct GME payments. In addition, as specified
in section 1886(h)(2)(D)(ii) of the Act, for cost reporting periods
beginning on or after October 1, 1993, through September 30, 1995, each
hospital's PRA for the previous cost reporting period is not updated
for inflation for any FTE residents who are not either a primary care
or an obstetrics and gynecology resident. As a result, hospitals with
both primary care and obstetrics and gynecology residents and
nonprimary care residents have two separate PRAs beginning in FY 1994:
one for primary care and obstetrics and gynecology and one for
nonprimary care.
Section 1886(h)(2) of the Act was further amended by section 311 of
Public Law 106-113 to establish a methodology for the use of a national
average PRA in computing direct GME payments for cost reporting periods
beginning on or after October 1, 2000, and on or before September 30,
2005. Generally, section 1886(h)(2) of the Act establishes a ``floor''
and a ``ceiling'' based on a locality-adjusted, updated, weighted
average PRA. Each hospital's PRA is compared to the floor and ceiling
to determine whether its PRA should be revised. PRAs that are below the
floor, that is, 70 percent of the locality-adjusted, updated, weighted
average PRA, would be revised to equal 70 percent of the locality-
adjusted, updated, weighted average PRA. PRAs that exceed the ceiling,
that is, 140 percent of the locality-adjusted, updated, weighted
average PRA, would, depending on the fiscal year, either be frozen and
not increased for inflation, or increased by a reduced inflation
factor.
[[Page 39892]]
We implemented section 311 of Public Law 106-113 in the hospital
inpatient prospective payment system final rule published on August 1,
2000 (65 FR 47090). In that final rule, we set forth the methodology
for calculating the weighted average PRA and outlined the steps for
determining whether a hospital's PRA would be revised.
2. Amendments Made by Section 511 of Public Law 106-554
(Sec. 413.86(e)(4)(ii)(C) and (e)(5)(iv))
Section 511 of Public Law 106-554 amended section
1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of
the locality-adjusted national average PRA. In general, section 511
provides that, effective for cost reporting periods beginning on or
after October 1, 2001, and before October 1, 2002, PRAs that are below
85 percent of the respective locality-adjusted national average PRA
would be increased to equal 85 percent of that locality-adjusted
national average PRA. Accordingly, we proposed to implement section 511
by revising Sec. 413.86(e)(4)(ii)(C)(1) to incorporate this change and
by outlining the methodology for determining whether a hospital's
PRA(s) will be adjusted in FY 2002 relative to the increased floor of
the locality-adjusted national average PRA.
In the August 1, 2000 final rule (65 FR 47091 and 47092), as
implemented at Sec. 413.86(e)(4), we determined, in accordance with
section 311 of Public Law 106-113, that the weighted average PRA for
cost reporting periods ending during FY 1997 is $68,464. We described
the procedures for updating the weighted average PRA of $68,464 for
inflation to FY 2001 and for adjusting this average for the locality of
each individual hospital. We then outlined the steps for comparing each
hospital's PRA(s) to the locality-adjusted national average PRA to
determine if, for cost reporting periods beginning on or after October
1, 2000, and before October 1, 2001, the PRAs should be revised to
equal the 70-percent floor.
In accordance with section 511 of Public Law 106-554, in the May 4
proposed rule, we proposed that, for cost reporting periods beginning
during FY 2002, the FY 2002 PRAs of hospitals that are below 85 percent
of the respective locality-adjusted national average PRA for FY 2002 be
increased to equal 85 percent of that locality-adjusted national
average PRA. Specifically, to determine which PRAs (primary care and
nonprimary care separately) for each hospital are below the 85-percent
floor, each hospital's locality-adjusted national average PRA for FY
2002 is multiplied by 85 percent. This resulting number is then
compared to each hospital's PRA that is updated for inflation to FY
2002. If the hospital's PRA would be less than 85 percent of the
locality-adjusted national average PRA, the individual PRA is replaced
with 85 percent of the locality-adjusted national average PRA for that
cost reporting period, and in future years the new PRA would be updated
for inflation by the Consumer Price Index for All Urban Consumers (CPI-
U) as compiled by the Bureau of Labor Statistics.
There may be some hospitals with both primary care and nonprimary
care PRAs that are below the floor, and both PRAs are, therefore,
replaced with 85 percent of the locality-adjusted national average PRA.
In these situations, the hospitals would receive a single PRA; a
distinction between PRAs would no longer be made based on the different
inflation adjustments (under Sec. 413.86(e)(3)(ii)). On the other hand,
hospitals may have primary care PRAs that are above the floor, and
nonprimary care PRAs that are below the floor. In these situations,
only the nonprimary care PRAs would be revised to equal 85 percent of
the locality adjusted national average PRA, and the prior year primary
care PRAs would be updated for inflation by the CPI-U. An example of
application of this provision appeared in the preamble of the May 4,
2001 proposed rule (66 FR 33697).
We note that section 511 of Public Law 106-554 only affects
hospitals with PRAs below the 85-percent floor, and does not affect
hospitals with PRAs that are either between the floor and ceiling or
exceed the ceiling. Thus, with the exception of the change in the floor
as provided by section 511, the policy regarding the use of a national
average PRA for making direct GME payments remains as implemented in
the regulations at Sec. 413.86(e)(4).
We proposed to amend Sec. 413.86(e)(4)(ii)(C)(1) to add the rules
implementing section 1886(h)(2)(D)(iii) of the Act as amended by
section 511 of Public Law 106-554.
We also proposed to amend Sec. 413.86(e)(5) regarding the
determination of base year PRAs for new teaching hospitals for cost
reporting periods beginning during FYs 2001 through 2005. In the August
1, 2000 final rule, we made a conforming change to Sec. 413.86(e)(5) to
account for situations in which hospitals do not have a 1984 base year
PRA and establish a PRA in a cost reporting period after the 1984 base
year. Existing Sec. 413.86(e)(5)(iv) specifies that the new base year
PRAs of such hospitals are subject to the regulations regarding the
floor and the ceiling of the locality-adjusted national average PRA.
Although the determination of new base year PRAs is subject to the
national average methodology, it is not necessary to include this
provision in the regulations. Therefore, we proposed to remove
Sec. 413.86(e)(5)(iv).
In the proposed rule, we clarified that, for purposes of
calculating a base year PRA for a new teaching hospital, when
calculating the weighted mean value of PRAs of hospitals located in the
same geographic area or the weighted mean value of the PRAs in the
hospital's census region (as defined in Sec. 412.62(f)(1)(i)), the PRAs
used in the weighted average calculation must not be less than the
floors for cost reporting periods beginning during FY 2001 or FY 2002,
or if they exceed the ceiling, they must either be frozen for FYs 2001
and 2002 or updated with the CPI-U minus 2 percent for FYs 2003 through
2005. In addition, existing Sec. 413.86(e)(5) provides that the PRA for
a new teaching hospital is based on the lower of the hospital's actual
costs incurred in connection with the GME program or the weighted mean
value of PRAs. If a hospital's actual costs of the GME program during
its cost reporting period beginning during FY 2001 or FY 2002 are less
than the floors, the hospital's PRA would not be based on the actual
costs. Instead, it would be equal to 70 percent in FY 2001, or 85
percent during FY 2002, of the locality-adjusted national average PRA.
The floor applies to hospitals with existing PRAs in FYs 2001 and 2002,
or to hospitals that are establishing new base year PRAs in FYs 2001
and 2002. We proposed to clarify that if a hospital establishes a new
base year PRA in a cost reporting period beginning after FY 2002, its
PRA would not be increased to equal the floor if it is less than the
floor. Similarly, the ceiling applies to hospitals with existing PRAS
in FYs 2001 through 2005, or to hospitals that are establishing new
base year PRAs in FYs 2001 through 2005.
Comment: One commenter believed that the provision to increase the
PRA floor to 85 percent of the locality-adjusted national average will
address many concerns about the fairness of GME payments. One commenter
asked if the provisions of the proposed rule to increase PRAs that are
less than 85 percent of the locality-adjusted national average PRA to
equal 85 percent of the locality-adjusted national average PRA would
provide relief to hospitals who do not have base year PRAs established
in the 1984 base year and could not increase their PRAs because the
appeal period has elapsed.
[[Page 39893]]
Response: Section 511 of the Public Law 106-554 amended section
1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of
the locality adjusted national average PRA. Effective for cost
reporting periods beginning on or after October 1, 2001 and before
October 1, 2002, any PRAs that are below 85 percent of the respective
locality-adjusted national average PRA would be increased to equal 85
percent of that locality-adjusted national average PRA. Accordingly,
hospitals with PRAs (primary care and/or nonprimary care) that are less
than 85 percent of the respective locality-adjusted national average
PRA for the hospital's cost reporting period beginning on or after
October 1, 2001 and before October 1, 2002, will have those PRAs
increased to equal 85 percent of that locality-adjusted national
average PRA. This provision sets the floor on per resident amounts for
cost reporting periods beginning during FY 2002, regardless of the base
year used to establish the hospital's PRA.
Comment: One commenter requested that we clarify the references in
the preamble stating that the national average PRA methodology is
applicable for ``cost reporting periods beginning on or after October
1, 2000 and on or before September 30, 2005.'' The commenter believed
that the PRA changes authorized in the law were meant to be permanent,
and therefore, did not understand the basis for the September 30, 2005
endpoint.
Response: The changes made to a hospital's PRA as a result of
section 311 of Public Law 106-113 and section 511 of Public Law 106-554
are permanent. However, this new methodology for determining whether or
not a hospital's PRA is revised, as described in the statute, is only
effective for cost reporting periods beginning on or after October 1,
2000 and on or before September 30, 2005. For cost reporting periods
beginning on or after October 1, 2005, a hospital's PRA, whether or not
it was revised by the new methodology, is updated with the full CPI-U,
using the procedures in place prior to October 1, 2000. If a hospital's
PRAs are below the floors, they will be revised accordingly in FYs 2001
or 2002, or both. After FY 2002, that hospital's revised PRA will be
updated for inflation as usual, that is, using the procedures in place
for all PRAs prior to October 1, 2000. If a hospital's PRAs exceed the
ceiling, the PRAs would be frozen in FYs 2001 and 2002, and updated
with a reduced inflation factor in FYs 2003, 2004, and 2005. Thus,
after September 30, 2005, although any changes made to a hospital's
PRAs as a result of the new methodology would remain in place, the
procedure for updating PRAs reverts back to the procedure in place
prior to October 1, 2000, that is, updating for inflation with the full
CPI-U.
Comment: One commenter requested that we publish in the final rule
the CPI-U factors that must be used to update the 1997 national average
PRA to the midpoint of a hospital's cost reporting period beginning in
FY 2001.
Response: As the commenter requested, we are including below the
CPI-U factors. For cost reporting periods beginning on or after October
1, 2000 and before October 1, 2001, the following update factors should
be used when implementing section 311 of Public Law 106-113. Specific
instructions for applying these factors can be found in the hospital
inpatient prospective payment system final rule published on August 1,
2000 (65 FR 47091). (Refer to the bottom of the middle column and the
right column on page 47091 for ``Step 1: Update the weighted average
PRA for inflation''.)
GME Update Factors for Midpoint of Periods Ending in FY 1997 to Cost
Reporting Periods Beginning in FY 2001 Using the CPI (U)--All Items
------------------------------------------------------------------------
To midpoint of cost
Update weighted average PRA reporting period Use update
from: beginning: factor of: \*\
------------------------------------------------------------------------
October 1, 1996................ October 1, 2000........ 1.11200
October 1, 1996................ November 1, 2000....... 1.11389
October 1, 1996................ December 1, 2000....... 1.11579
October 1, 1996................ January 1, 2001........ 1.11800
October 1, 1996................ February 1, 2001....... 1.12053
October 1, 1996................ March 1, 2001.......... 1.12307
October 1, 1996................ April 1, 2001.......... 1.12465
October 1, 1996................ May 1, 2001............ 1.12528
October 1, 1996................ June 1, 2001........... 1.12591
October 1, 1996................ July 1, 2001........... 1.12780
October 1, 1996................ August 1, 2001......... 1.13097
October 1, 1996................ September 1, 2001...... 1.13414
------------------------------------------------------------------------
\*\ Source: Forecast by Standard and Poor's DRI; Historical Data through
August 2000.
3. Determining the 3-Year Rolling Average for Direct GME Payments
(Sec. 413.86(g)(4) and (g)(5))
Section 1886(h)(4)(G)(iii) of the Act, as added by section 4623 of
Public Law 106-33, provides that for the hospital's first cost
reporting period beginning on or after October 1, 1997, the hospital's
weighted FTE count for direct GME payment purposes equals the average
of the weighted FTE count for that cost reporting period and the
preceding cost reporting period. For cost reporting periods beginning
on or after October 1, 1998, section 1886(h)(4)(G) of the Act requires
that hospitals' direct medical education weighted FTE count for payment
purposes equal the average of the actual weighted FTE count for the
payment year cost reporting period and the preceding two cost reporting
periods (rolling average). This provision phases in the associated
reduction in payment over a 3-year period for hospitals that are
reducing their number of residents.
In the August 29, 1997 final rule with comment period (62 FR
46004), we revised Sec. 413.86(g)(5) accordingly, and outlined the
methodology for determining a hospital's direct GME payment. Based on
what we explained in the 1997 final rule, for cost reporting periods
beginning on or after October 1, 1997, we would determine a hospital's
direct GME payment as follows:
Step 1. Determine the average of the weighted FTE counts for the
payment year cost reporting period and the prior two immediately
preceding cost reporting periods (with exception of the hospital's
first cost reporting period beginning on or after October 1, 1997,
which will be based on the average of the weighted average for that
cost
[[Page 39894]]
reporting period and the immediately preceding cost reporting period).
Step 2. Determine the hospital's direct GME amount without regard
to the FTE cap (before determining Medicare's share). That is, take the
sum of (a) the product of the primary care PRA and the primary care
weighted FTE count in the current payment year, and (b) the product of
the nonprimary care PRA and the nonprimary care weighted FTE count in
the current payment year.
Step 3. Divide the hospital's direct GME amount by the total number
of FTE residents (including the effect of weighting factors) for the
cost reporting period to determine the weighted average PRA (this
amount reflects the FTE weighted average of the primary and nonprimary
care PRAs) for the cost reporting period.
Step 4. Multiply the weighted average PRA for the cost reporting
period by the 3-year average weighted count to determine the hospital's
allowable direct GME costs. This product is then multiplied by the
hospital's Medicare patient load for the cost reporting period to
determine Medicare's direct GME payment to the hospital.
Steps 2 and 3 above describe the methodology for combining a
hospital's primary care PRA and nonprimary care PRA to determine the
hospital's single weighted average PRA for the payment year cost
reporting period. (This step accounts for hospitals that were training
residents in both primary care and nonprimary care residency programs
in FYs 1994 and 1995, when, as described in Sec. 413.86(e)(3)(ii), each
hospital's PRA for the previous cost reporting period was not adjusted
for any resident FTEs who were not either a primary care resident or an
obstetrics and a gynecology resident. As a result, such hospitals have
two PRAs for direct GME payment; one for primary care and obstetrics
and gynecology residents, and one for all other, or nonprimary care,
residents. Hospitals that train either only primary care (including
obstetrics and gynecology) residents or only nonprimary care residents
follow the methodology described above, with the exception of combining
two PRAs. Step 4 then dictates that the resulting average PRA is
multiplied by the 3-year rolling average, which, in turn, is multiplied
by the hospital's Medicare patient load in the current year to
determine Medicare's direct GME payment to the hospital for that cost
reporting period.
In implementing this provision in the August 29, 1997 final rule
with comment period, we believed that the methodology described above
was appropriate because it was consistent with the methodology
described under section 1886(h)(3)(B) of the Act. This section
specifies that, in order to arrive at the average PRA, or ``aggregate
approved amount,'' the Secretary must multiply a hospital's PRA by the
``weighted average number of [FTE] residents * * * in the hospital's
approved medical residency training programs in that period'' (emphasis
added).
We also believed the methodology outlined above and in the August
29, 1997 rule was appropriate because it was consistent with the intent
of the statute that, after October 1, 1997, direct GME payments should
be based on a rolling average. Specifically, section 4623 of Public Law
106-33 provides that, ``For cost reporting periods beginning on or
after October 1, 1997 * * * the total number of full-time equivalent
residents for determining a hospital's graduate medical education
payment shall equal the average of the actual full-time equivalent
resident counts for the cost reporting period and the preceding two
cost reporting periods' (emphasis added). Thus, while the statute does
not include a specific methodology for computing the direct GME
payments, it clearly indicates that the payment should be based on a 3-
year average of the weighted number of residents, not the weighted
number of residents in the current payment year cost reporting period.
As stated above, Congress provided that the direct GME payments
should be made based on a 3-year average of the weighted number of
residents in order to phase in the associated reduction in payment over
a 3-year period for hospitals that are reducing the number of residents
they are training. However, in steps 2 and 3 above, when combining a
hospital's primary care PRA and nonprimary care PRA, we weight the
respective PRAs by current year residents. This introduces the number
of residents that a hospital is training in the current cost reporting
period into the payment formula. A payment formula that incorporates
the number of current year residents ``dilutes'' the effect of the
rolling average as related to direct GME payments. After further
consideration, we believe that, consistent with the statute, the
formula should be based on rolling average counts of residents. We
proposed an alternative methodology which would replace the current
methodology in which the direct GME payment would be the sum of (a) the
product of the primary care PRA and the primary care and obstetrics and
gynecology rolling average, and (b) the product of the nonprimary care
PRA and the nonprimary care rolling average. (This sum would then be
multiplied by the Medicare patient load.) The new methodology would
only be used for determining direct GME payments because there is no
distinction between primary care and nonprimary care residents for IME
payment purposes.
The new methodology is effective for cost reporting periods
beginning on or after October 1, 2001. The methodology for determining
a hospital's direct GME payment is as follows:
Step 1. Determine that the hospital's total unweighted FTE counts
in the payment year cost reporting period and the prior two immediately
preceding cost reporting periods for all residents in allopathic and
osteopathic medicine do not exceed the hospital's FTE cap for these
residents in accordance with Sec. 413.86(g)(4). If the hospital's total
unweighted FTE count in a cost reporting period exceeds its cap, the
hospital's weighted FTE count, for primary care and obstetrics and
gynecology residents and nonprimary care residents, respectively, will
be reduced in the same proportion that the number of these FTE
residents for that cost reporting period exceeds the unweighted FTE
count in the cap. The proportional reduction is calculated for primary
care and obstetrics and gynecology residents and nonprimary care
residents separately in the following manner:
(FTE cap/unweighted total FTEs in the cost reporting period) x
(weighted primary care and obstetrics and gynecology FTEs in the
cost reporting period)
plus
(FTE cap/unweighted total FTEs in the cost reporting period) x
(weighted nonprimary care FTEs in the cost reporting period).
Add the two products to determine the hospital's reduced cap.
Step 2. Determine the 3-year average of the weighted FTE count for
primary care and obstetrics and gynecology residents in the payment
year cost reporting period and the two immediately preceding cost
reporting periods. Determine the 3-year average of the weighted FTE
count for nonprimary care residents in the payment year cost reporting
period and the two immediately preceding cost reporting periods.
Step 3. Determine the product of the primary care PRA and the
primary care and obstetrics and gynecology 3-year average from step 2.
Determine the product of the nonprimary care PRA and the nonprimary
care 3-year average from step 2.
Step 4. Sum the products of step 3.
Step 5. Multiply the sum from step 4 by the hospital's Medicare
patient load
[[Page 39895]]
for the cost reporting period to determine Medicare's direct GME
payment to the hospital.
Existing Sec. 413.86(g)(5) specifies that residents in new programs
are excluded from the rolling average calculation for a period of years
equal to the minimum accredited length for the type of program, and are
added to the payment formula after applying the averaging rules.
Accordingly, for hospitals that qualify for an adjustment to their FTE
caps for residents training in new programs under Sec. 413.86(g)(6),
primary care and obstetrics and gynecology residents in new programs
would be added to the quotient of the primary care and obstetrics and
gynecology 3-year average, and nonprimary care residents in new
programs would be added to the quotient of the nonprimary care 3-year
average. The sums of the respective 3-year averages and new residents
would then be multiplied by the respective PRAs.
The following example illustrates the determination of direct GME
payment under the proposed rolling average methodology for an existing
teaching hospital with no new programs:
Example: Assume a hospital with a cost reporting period ending
September 30, 1996 (beginning October 1, 1995) had 100 unweighted
FTE residents and 90 weighted FTE residents. The hospital's FTE cap
is 100 unweighted residents.
Step 1. In its cost reporting period beginning in FY 2000, it had
100 unweighted residents and 90 weighted residents (50 primary care and
40 nonprimary care).
The hospital had 90 unweighted residents and 85 weighted
residents (50 primary care and 35 nonprimary care) for its cost
reporting period beginning in FY 2001.
In its cost reporting period beginning in FY 2002, the
hospital had 80 unweighted residents and 80 weighted residents (50
primary care and 30 nonprimary care).
Step 2. The 3-year average of weighted primary care and obstetrics
and gynecology residents is (50 +50 + 50)/3 = 50. The 3-year average of
weighted nonprimary care residents is (40 + 35 + 30)/3 = 35.
Step 3. Primary care: $80,000 PRA x 50 weighted primary care and
obstetrics and gynecology FTEs = $4,000,000. Nonprimary care: $78,000
x 35 weighted nonprimary care FTEs = $2,730,000.
Step 4. $4,000,000 + $2,730,000 = $6,730,000.
Step 5. If the hospital's Medicare patient load for the payment
cost reporting period is .20, Medicare's direct GME payment would be
$6,730,000 x .20 = $1,346,000.
Whether the proposed methodology results in a payment difference
for a hospital is dependent upon whether or not the number and mix
(primary care and nonprimary care) of FTEs changes in a 3-year period.
If the number and mix of FTEs does not change in a 3-year period, there
would be no difference in a direct GME payment amount derived using the
proposed methodology versus the existing methodology. For example, if a
hospital has 90 weighted FTEs (50 primary care and 40 nonprimary care)
in the current year and the 2 previous years (using the PRAs and the
Medicare patient load from the example above), the payment amounts
derived from the existing methodology and the proposed methodology
would be equal.
If the number and mix of FTEs varies from year to year, there will
be a difference in the results of the two methodologies. In some
instances the existing methodology would result in a higher payment,
and in other instances the proposed methodology would result in a
higher payment. In the example above, the hospital has reduced its
number of weighted residents by 5 FTEs in FYs 2001 and 2002.
Calculating this hospital's direct GME payment amount using the
existing methodology (using the PRAs and the Medicare patient load from
the example) would result in a payment of $1,347,250, which is $1,250
more than $1,346,000, the amount calculated in the example using the
proposed methodology.
In a scenario where a hospital makes larger reductions to the
number of FTEs, the proposed methodology may be more beneficial. For
example, using the PRAs and the Medicare patient load from the example
above, assume a hospital has 90 weighted FTEs (50 primary care and 40
nonprimary care) in FY 2000, 85 weighted FTEs (50 primary care and 35
nonprimary care) in FY 2001, and 70 weighted FTEs (35 primary care and
35 nonprimary care) in FY 2002. If the proposed methodology is used,
the payment amount of $1,292,050 would be calculated, which is $1,666
more than $1,290,386, the amount calculated if the existing methodology
is used.
We proposed to revise Sec. 413.86(g)(4) to specify that, effective
for cost reporting periods beginning on or after October 1, 2001, if
the hospital's total unweighted FTE count in a cost reporting period
exceeds its cap, the hospital's weighted FTE count, for primary care
and obstetrics and gynecology residents and nonprimary care residents,
respectively, will be reduced in the same proportion that the number of
these FTE residents for that cost reporting period exceeds the
unweighted FTE count in the cap. We also proposed to revise
Sec. 413.86(g)(5) to specify that, effective for cost reporting periods
beginning on or after October 1, 2001, the direct GME payment will be
calculated using two separate rolling averages, one for primary care
and obstetrics and gynecology residents and one for nonprimary care
residents.
Comment: Two commenters asked whether or not the proposed new
methodology for calculating direct GME payment using two separate
rolling averages for primary care and nonprimary care residents is
truly an ``alternative,'' or, if finalized, would it replace the
present methodology.
Response: The proposed new methodology would replace the existing
rolling average methodology effective for cost reporting periods
beginning on or after October 1, 2001 (the effective date of this final
rule). Hospitals training both primary care and nonprimary care
residents would determine two separate rolling average counts; one for
primary care and one for nonprimary residents.
Comment: One commenter stated: ``although the new rolling average
methodology is difficult and complex, its impact on GME programs is far
from clear.'' The commenter asked how much change in resident number
and mix is necessary before this new methodology has an effect on
payment, and stated that more examples would be helpful in determining
this effect. The commenter also expressed hope that, if this change is
finalized, we will revisit this issue after implementation and fully
examine and analyze its impact on teaching program payment.
Response: As we explained in the proposed rule, whether the new
methodology results in a payment difference for a hospital is dependent
upon whether or not the ratio of primary care to nonprimary care FTEs
changes in a 3-year period. If the ratio of the FTEs does not change
over the 3-year period, there would be no difference in a direct GME
payment amount derived using the new methodology versus the existing
methodology. In particular, there would be an increase in direct GME
payment under the revised methodology, where a hospital's proportion of
primary care residents to nonprimary care residents over the last 3
years is higher than the hospital's proportion of primary care
residents to nonprimary care residents in the current year. As this new
rolling average methodology is implemented, we intend to evaluate
hospitals' direct GME payments to further analyze the impact of using
this methodology.
Comment: One commenter asked how many hospitals would still be ``at
risk''
[[Page 39896]]
for changes in payment because they retain different primary care and
nonprimary care PRAs, given the implementation of the 85 percent floor.
Response: As described in the impact section of this final rule in
Appendix A, we estimated that, of 1,231 teaching hospitals included in
the analysis, approximately 562 hospitals have PRAs that will be
increased to equal 85 percent of the national average PRA. This leaves
669 hospitals with PRAs that exceed the 85 percent floor. However, not
all of these hospitals will be using the new methodology because not
all of them have both primary care and nonprimary care PRAs.
Comment: One commenter noted that, in order to implement the new
rolling average methodology, significant changes must be made to
Worksheet E, Part A, the worksheet on the Medicare cost report used for
calculating a hospital's IME adjustment. The commenter also stated that
past cost reports using the current cost reporting forms would have to
be reopened.
Response: As we explained in the preamble to the proposed rule and
above in this final rule, we have decided to institute a separate
rolling average for primary care and nonprimary care residents due to
an issue with respect to the current payment methodology for direct GME
only. That is, when combining a hospital's primary care PRA and
nonprimary care PRA on Worksheet E-3, Part IV of the Medicare cost
report, we currently weight the respective PRAs by current year
residents. As a result, although Congress provided that the direct GME
payments should be made based on a 3-year rolling average count of
weighted residents, the current methodology introduces the number of
residents that a hospital is training in the current cost reporting
period into the payment formula. A payment formula that incorporates
the number of current year residents ``dilutes'' the effect of the
rolling average as related to direct GME payments. However, in regard
to the IME payments, we also noted that, although they are also based
on a rolling average, no change in the existing methodology is needed
because there is no distinction between primary care and nonprimary
care residents for IME payment purposes. Therefore, while two separate
rolling averages will be used for direct GME payments (one for primary
care and one for nonprimary care), a single rolling average will
continue to be used for IME payments under the existing methodology. We
will make the necessary changes to the Medicare cost report on
Worksheet E-3, Part IV, which is used for calculating a hospital's
direct GME payment, to accommodate two separate rolling average
calculations.
The commenter also stated that affected cost reports in which the
current rolling average methodology was used would need to be reopened.
However, the effective date of this change in the methodology is
prospective, and will only affect cost reporting periods beginning on
or after October 1, 2001. We will not be reopening past cost reports to
change direct GME payment because of the new methodology.
Comment: One commenter indicated that the separation of the 3-year
rolling average between primary care and nonprimary care FTEs will be
difficult because the prior year FTEs were not separated into primary
care and nonprimary care FTEs. The commenter asked how a provider could
obtain the information from prior years if the same methodology was not
used.
Response: We do not believe it will be difficult for a hospital to
obtain the weighted FTE counts of its primary care and nonprimary care
residents separately. This is because, in fact, although the rolling
average was computed based on total residents, there are lines on
Worksheet E-3, Part IV (lines 3.07 and 3.08) in which the current year
weighted count of primary care and nonprimary care residents are
reported separately. Therefore, the hospital and the fiscal
intermediary can easily refer to these lines on prior year cost reports
to determine a 3-year average for primary care and nonprimary care
residents, respectively.
4. Counting Research Time as Direct and Indirect GME Costs
(Secs. 412.105 and 413.86)
It has come to our attention that there appears to be some
confusion in the provider community as to whether the time that
residents spend performing research is countable for the purposes of
direct and indirect GME reimbursement. Although we did not propose to
make any policy changes in the May 4 proposed rule, we did reiterate
our longstanding policy regarding time that residents spend in research
and proposed to incorporate this policy in the IME regulations.
Section 413.86(f) specifies that, for the purposes of determining
the total number of FTE residents for the direct GME payment, residents
in an approved program working in all areas of the hospital complex may
be counted. Accordingly, the time the residents spend performing
research as part of an approved program anywhere in the hospital
complex may be counted for direct GME payment purposes. If the
requirements listed at Secs. 413.86(f)(3) and (f)(4) are met, a
hospital may also count the time residents spend doing research in
nonhospital settings for direct GME payment.
For purposes of determining the IME payment, Sec. 412.105(f)(1)(ii)
specifies that the time residents spend training in parts of the
hospital that are subject to the inpatient prospective payment system,
in the outpatient departments, or (effective on or after October 1,
1997, in accordance with Sec. 413.86(f)(3) or (f)(4), as applicable) in
nonhospital settings, may be counted. Section 2405.3.F.2. of the
Provider Reimbursement Manual (PRM) further states that a resident must
not be counted for the IME adjustment if the resident is engaged
exclusively in research. Resident time spent ``exclusively'' in
research means that the research is not associated with the treatment
or diagnosis of a particular patient of the hospital. Therefore,
although the research component may be part of an approved program, the
time that residents devote specifically to performing research that is
not related to delivering patient care, whether it occurs in the
hospital complex or in non-hospital settings, may not be counted for
IME payment purposes. ``Exclusively research'' time is not allowable
for IME purposes irrespective of whether the resident is engaged only
in research or spends only part of his or her time on research.
Accordingly, time spent exclusively in research over the course of a
program year should be subtracted from the total FTE count for that
year. For example, if a resident is required to spend 3 months in a
particular program year engaged in research activities unrelated to
delivering patient care, that amount of time should be subtracted from
the total FTE count, whether or not the research time is fulfilled in
one block of time, or is distributed throughout the training year.
We note that in order to count residents for both direct GME and
IME payment purposes, the residents' training must be part of an
approved program. This applies whether or not the residents are doing
work that is clinical in nature. There are situations where residents
have completed their residency program requirements but remain for an
additional period of time to continue their training (that is, to
conduct research or other activities) outside the context of a formally
organized approved program. As we explained in the September 29, 1989
final rule (54 FR 40306), these residents are not countable for direct
GME or IME
[[Page 39897]]
reimbursement. Rather, patient care services provided by these
residents should be paid as Part B services.
We proposed to amend Sec. 412.105(f)(1)(iii) to add a paragraph (B)
to incorporate language that reflects this policy.
We received several comments disagreeing with our clarification to
longstanding policy on whether the time that residents spend performing
research may be included in the FTE count for the purpose of
determining direct and indirect GME reimbursement.
Comment: One commenter stated that the proposed revised IME
regulations at Sec. 412.105 do not mention any requirement that
residents counted for purposes of the IME adjustment and assigned to a
hospital's inpatient prospective payment system or outpatient area be
involved in ``patient care activities.'' Instead, that requirement is
only mentioned with reference to residents assigned to nonprovider
settings. Therefore, the commenter believed that a patient care
requirement in reference to counting residents in nonprovider settings
implies the exclusion of the same requirement when counting residents
in the hospital (specifically as it applies to counting research time
for IME purposes).
Response: The clarification in the proposed rule addresses our
longstanding interpretation of existing regulations and reflects
longstanding general Medicare reimbursement principles. Under general
Medicare reimbursement principles, as reflected in Sec. 413.9, costs
incurred by a hospital generally must be related to patient care in
order to be reimbursed by Medicare.
The purpose of the IME payments is to address the additional costs
that hospitals incur in treating patients. In our May 6, 1986 interim
final rule (51 FR 16775), we stated: ``Section 1886(d)(5)(B) of the Act
provides that prospective payment hospitals receive an additional
payment for the indirect costs of medical education computed in the
same manner as the adjustments for those costs under regulations in
effect as of January 1, 1983. Under those regulations, we provided that
the indirect costs of medical education incurred by teaching hospitals
are the increased operating costs (that is, patient care costs) that
are associated with approved intern and resident programs'' (emphasis
added). In addition, in our September 29, 1989 final rule (54 FR
40286), we specifically state: ``As used in section 1886(d)(5)(B) of
the Act, `indirect medical education' means those additional costs
(that is, patient care costs) incurred by hospitals with graduate
medical education programs. The indirect costs of medical education
might, for example, include added costs resulting from an increased
number of tests ordered by residents as compared to the number of tests
normally ordered by more experienced physicians'' (emphasis added).
Thus, payments for IME address the additional operating costs that
teaching hospitals incur in furnishing patient care. Accordingly,
consistent with the purpose of IME payments and general Medicare
reimbursement principles, in determining the FTE count with respect to
the IME adjustment, it has been our longstanding policy that we do not
include residents to the extent that the residents are not involved in
furnishing patient care but are instead engaged exclusively in
research.
Comment: One commenter disagreed with our use of the Provider
Reimbursement Manual (PRM), section 2405.3.F.2, in support of our
policy on excluding residents from the IME count if the resident is
``engaged exclusively in research.'' The commenter stated that the
reference to exclusion from the resident count for residents engaged
``exclusively in research'' must be read in the context of the Manual
provision, and not in a regulatory vacuum. The commenter believed that
PRM section 2405.3.F.2 is addressing situations outside of the
traditional residency program--where the resident time at issue is not
part of an approved medical education program. The commenter believed
that the phrase ``engaged exclusively in research'' refers to persons
who are research scientists and not engaged in research as part of a
clinical residency program.
In addition, this commenter stated that our interpretation of the
word ``exclusively'' in this context is not reasonable and is contrary
to the clear meaning of the term. The commenter argued that our
interpretation practically eliminates the word ``exclusively,''
effectively saying that a resident is ``exclusively engaged in
research'' if that resident participates in any research at all.
Response: Section 2405.3.F.2 of the PRM (published in August 1988)
was written to address ``Questionable situations'' for the IME FTE
count. Indeed, in the introductory paragraph in this section we state:
``It is recognized that situations arise in which it may be unclear
whether an individual is counted as an intern or resident in an
approved program for the purposes of the indirect medical education
adjustment.'' Thus, the point of section 2405.3.F.2 of the PRM was to
clarify situations for counting resident FTEs in approved programs for
IME purposes. As the commenter suggested, some of the situations listed
under this section address situations where the resident FTE time at
issue is not part of the approved medical education program (for
example, that a resident must not be counted for the IME adjustment if
``the individual's services in provider settings are payable as
physician services (situations in which it is clear that the otherwise
eligible resident is `moonlighting')''.) (Section 2405.3.F.2. of the
PRM). However, this section in the PRM was written to clarify counting
rules for IME purposes in various situations. In addition to clarifying
situations where resident time is spent in an unapproved program, this
section in the PRM certainly also clarifies the rules for determining
resident time spent in an approved program--such as time the resident
is ``engaged exclusively in research'' (as cited in the proposed rule)
and that ``any portion of the individual's salary is subject to
reasonable compensation equivalency limits.'' (Section 2405.3.F.2. of
the PRM)
Therefore, we do not agree with the commenter that we have read
this manual provision in a ``regulatory vacuum''. The phrase ``engaged
exclusively in research'' is not meant only to refer to persons who are
research scientists and not engaged in research as part of an approved
clinical residency program, since as explained above, there is nothing
in the manual provision that limits the research provision to research
performed outside of an approved program.
In the proposed rule, we stated that resident time spent
``exclusively'' in research ``means that the research is not associated
with the treatment or diagnosis of a particular patient of the
hospital.'' (66 FR 22700). The commenter argued that this
interpretation of the word ``exclusively'' in the context of the manual
provision is unreasonable and contrary to the clear meaning of the
term, that under our policy, a resident would be ``engaged exclusively
in research'' if that resident participates in any research at all. We
do not agree.
Resident time spent ``engaged exclusively in research'' means time
not associated with the care of a particular patient (see proposed
Sec. 412.105(f)(1)(iii)(B)); thus, any research time that is associated
with the treatment or diagnosis of a particular hospital patient or,
effective on or after October 1, 1997, of patients in nonhospital
settings, that is, usual patient care, is countable for IME payment
purposes. We note that this distinction between activities that are
[[Page 39898]]
``usual patient care'' and research activities is, again, longstanding
Medicare policy. In April 1975, at section 500 of the PRM, we stated
the principle that ``Costs incurred for research purposes, over and
above usual patient care, are not included as allowable costs.''
Indeed, since the inception of Medicare, we have distinguished between
activities that are ``usual patient care'' and activities that are
outside this scope, such as research activities.
Comment: One commenter stated that ``by its very nature as a
regression analysis, or statistical measure, the IME formula is not
intended to be dependent on `the treatment or diagnosis of a particular
patient of the hospital.' '' Another commenter stated: ``our
understanding of the development of the adjustment is that statistical
analyses showed that the use of an intern/resident-to-bed ratio (IRB)
was (and continues to be) the best proxy for the patient care cost
differences between teaching and non-teaching hospitals. Given that the
IRB is only a proxy, the relevance of a requirement that residents
themselves must be engaged in activities related to patient care in
order for their training time to be counted in the IRB is unclear.''
Response: Generally, the statistical analyses used in the
development of the statutory IME adjustment measured the differences
between teaching and nonteaching hospitals with respect to the
additional costs associated with patient care. Inpatient hospital care
that involves the use of residents is costlier than inpatient hospital
care that does not involve the use of residents. As the comments and
the statute reflect, the hospital's ratio of interns and residents to
beds is one factor in measuring the additional costs that a hospital
incurs due to the use of residents in furnishing patient care. While a
resident is engaged exclusively in research, the hospital is not
incurring additional patient care costs due to that resident.
Accordingly, we believe that the measure of additional patient care
costs is more accurate if it excludes residents engaged exclusively in
research.
Suppose, for example, that a teaching hospital has a total of 20
FTE residents training in prospective payment system sections of the
hospital who are all involved in furnishing patient care. The amount of
the IME payment to the hospital would reflect 20 FTE residents,
reflecting the additional operating costs arising from the use of 20
FTE residents in furnishing patient care. Now suppose that the same
hospital has the same 20 residents involved in furnishing patient care
but it also has 4 additional FTE residents engaged exclusively in
research. The 4 residents engaged exclusively in research do not
contribute to higher operating costs and, therefore, as our
longstanding policy reflects, we believe it is appropriate not to count
them for purposes of the IME adjustment. Thus, in both situations, the
hospital's FTE count for purposes of IME is 20. If we did make higher
payments in the second situation, then the hospital would receive
higher payments even though the hospital did not incur higher patient
care costs.
Comment: One commenter stated that our regulations at
Sec. 413.86(e)(1)(i)(B) clearly allow research time to be counted for
direct GME purposes. This commenter asserted that ``it cannot be
reasonably argued that research time should be counted differently for
IME than direct GME based on a new, very specific definition of patient
care that applies solely to IME''. Another commenter stated the
proposed rule is ``unduly burdensome'' by requiring hospitals to
maintain different counts for direct GME and IME based on research
activity or rotations. A third commenter stated that there is an
alternative to distinguishing between direct GME and IME as it relates
to research--``lawyers, often when faced with conflicting sections of
the law, attempt to reconcile a common policy out of these conflicts,
rather than further complicating things. You could do the same here.''
Response: As we have stated above and in the proposed rule, the
clarification we made concerning the counting of FTEs for research time
related to the diagnosis and treatment of a particular patient for IME
purposes is longstanding Medicare reimbursement policy. We were not
proposing a change in Medicare policy.
We are not introducing unnecessary complexity to the direct and
indirect medical education counts, since it has always been Medicare
policy to require the hospital to distinguish between time spent by
residents involved exclusively in research and time spent on patient
care. Further, the IME and direct GME FTE counts have and will continue
to differ for several reasons. Hospitals have always been able to count
residents in all areas of the hospital complex for direct GME but
cannot count residents working in units exempt from the prospective
payment system for IME. In addition, each resident included in the
hospital's direct GME FTE count is counted as 0.5 FTE if they have
trained beyond the number of years required to become eligible in the
specialty in which they first began training. These same residents are
counted as 1.0 FTE in the hospital's IME FTE count. We reiterate that
we are not making a change in policy, but merely clarifying our policy
with respect to counting residents involved in GME.
With respect to research, our policies for direct GME payment are
consistent with our policies for IME payment. In both contexts, we do
not pay for the costs of time spent by residents engaged exclusively in
research. In making payments for IME and direct GME for a given year,
it is true that we treat research time differently for purposes of the
IME FTE count and the direct GME FTE count, but, as explained below,
this difference arises from the direct GME base year methodology and
does not mean that we pay for research costs in the direct GME payment.
In the September 29, 1989 final rule implementing the direct GME
base year payment methodology, we described the calculation of the per
resident amounts (PRAs). Each hospital's PRA is determined by taking
the hospital's total allowable graduate medical education costs (which
do not include costs allocated to the nursery cost center, research,
and other nonreimbursable cost centers) in a base year and dividing the
costs by the number of FTE residents working in all areas of the
hospital complex in the base year. (Sec. 413.86(e)(1)(i)) In the case
of research and other nonreimbursable cost centers, costs were excluded
from the PRA calculation because they were nonreimbursable in the base
year, consistent with longstanding Medicare policy on Medicare cost
reimbursement to teaching hospitals. Ideally, residents engaged
exclusively in research would also have been excluded from the base
year FTE count used in the PRA calculation. However, for a number of
hospitals, the FTE count for the base year did include residents
engaged exclusively in research because the 1984 base year information
available when the PRAs were determined in 1990 did not distinguish
between residents involved in furnishing patient care services and
residents exclusively engaged in research.
In order to avoid disadvantaging these hospitals, in making direct
GME payments for a given year, we have included and continue to include
residents exclusively engaged in research in the direct GME FTE count
both in the base year PRA calculation and in the FTE count in
subsequent payment year calculations. Doing so ``offsets'' the effects
of the inclusion of such residents in the direct GME base year FTE
count (no such ``offset'' is necessary in the context of IME). However,
because the costs were
[[Page 39899]]
excluded in calculating the PRA, the end result is that the direct GME
payment does not encompass the costs of residents engaged exclusively
in research. Therefore, as with the IME payment, Medicare is not and
has not been reimbursing teaching hospitals under direct GME for costs
the hospital incurs associated with resident time spent in research
unrelated to usual patient care.
Comment: One commenter stated that our policy on counting research
time is well stated and clear. However, this commenter stated that
there is much research that is done outside any funding source, but is
an essential part of the resident's training. The commenter further
stated that the hospital does assume these costs, and they are not part
of the direct GME component, and so represent valid hospital
expenditures due to the presence of residents.
Response: We certainly acknowledge that hospitals incur research
costs associated with the training of interns and residents. We
understand that many specialties require a research component to be
completed as part of the specialties' board eligibility requirements.
The question as far as IME payments are concerned is whether or not the
research is associated with the diagnosis and treatment of a particular
patient. As explained above, teaching hospitals receive Medicare IME
payments to pay hospitals for Medicare's share of the additional costs
these hospitals incur associated with patient care costs; if the
research is not associated with usual patient care costs, then the
resident research time is not reimbursable.
Comment: Two commenters stated that they are concerned that
clarifications on the exclusion of resident FTEs from the IME payment
for trainees engaged in activities that are purely research would be
extended to include those individuals in an approved program that
requires research activities at the same time as the delivery of
patient care.
Response: As stated above, where the residents are engaged
exclusively in research, it is appropriate to exclude that time from
the IME payment calculation. However, consistent with longstanding
policy, in the situation where residents are in an approved program
participating in research activities that are associated with the
diagnosis and treatment of a particular patient, we believe it is
appropriate to include that time in the IME payment calculation.
5. Temporary Adjustments to FTE Cap to Reflect Residents Affected by
Residency Program Closure
In the July 30, 1999 hospital inpatient prospective payment system
final rule (64 FR 41522), we indicated that we would allow a temporary
adjustment to a hospital's FTE 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. We made
this change because hospitals had indicated a reluctance to accept
additional residents from a closed hospital without a temporary
adjustment to their caps. When we proposed this change 2 years ago, we
received several comments suggesting that we include lost accreditation
of a program (that is, a program's closure) in the temporary adjustment
policy. We explained in our response to these comments (64 FR 41522)
that we did not believe it was appropriate to expand our policy to
cover any acts other than a hospital's closure. We made this decision
because, unless the hospital terminates its Medicare agreement, the
hospital would retain its statutory FTE cap and could affiliate with
other hospitals to enable the residents to finish their training.
It has come to our attention that, despite a hospital's ability to
affiliate with other hospitals when it shuts down a residency program,
some hospitals for various reasons do not affiliate before their
programs close, particularly when the program closes abruptly towards
the end of the program year (the deadline to submit Medicare
affiliation agreements is July 1 of the upcoming program year).
Therefore, in the May 4 proposed rule, we proposed that if a hospital
that closes its residency training program agrees to temporarily reduce
its FTE cap, another hospital(s) may receive a temporary adjustment to
its FTE cap to reflect residents added because of the closure of the
former hospital's residency training program. For purposes of this
policy on closed programs, we proposed to define ``closure of a
hospital residency training program'' as when the hospital ceases to
offer training for residents in a particular approved medical residency
training program (proposed Sec. 413.86(g)(8)(i)(B)). The methodology
for adjusting the caps for the ``receiving hospital'' and the
``hospital that closed its program'' is described below.
a. Receiving hospital. We proposed that a hospital(s) may receive a
temporary adjustment to its (or their) FTE cap to reflect residents
added because of the closure of another hospital's residency training
program if--
The hospital is training additional residents from the
residency training program of a hospital that closed its program; and
No later that 60 days after the hospital begins to train
the residents, the hospital submits to its fiscal intermediary a
request 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 another hospital's closed program and have
caused the hospital to exceed its cap, specifies the length of time the
adjustment is needed, and submits to its fiscal intermediary a copy of
the FTE cap reduction statement by the hospital closing the program, as
specified in paragraph (g)(8)(iii)(B)(2).
In general, the proposed temporary adjustment criteria are
reflective of the temporary adjustment criteria for taking on the
training of displaced residents from closed hospitals. We note that we
proposed that more than one hospital would be eligible to apply for the
temporary adjustment, because residents from one closed program may go
to different hospitals, or they may finish their training at more than
one hospital. We also noted that only to the extent a hospital would
exceed its FTE cap by training displaced residents would it be eligible
for the temporary adjustment.
Finally, we proposed that hospitals that meet the proposed criteria
would be eligible to receive temporary adjustments (for cost reporting
periods beginning on or after October 1, 2001, for direct GME and with
discharges beginning on or after October 1, 2001 for IME) for training
the displaced residents from programs that closed even before the
effective date of this policy. We mentioned this because hospitals may
have closed programs in the recent past and the residents from the
closed programs may not have completed their training as of the
effective date of this policy. For instance, if a 5-year residency
program, such as surgery, closed on July 1, 1997, the 5th program year
residents may still be training during this residency year (2001). We
proposed that if both the receiving hospital(s) and the hospital that
closed the program in this example follow the criteria described in
this preamble, the receiving hospital may receive a temporary
adjustment to its FTE cap for 9 months (October 1, 2001 through June
30, 2002) to accommodate the 5th year surgery residents. However, we
noted that hospitals would not be eligible to receive a temporary
adjustment for
[[Page 39900]]
training the residents until the effective date of this rule (that is,
October 1, 2001).
b. Hospital that closed its program(s). We proposed that a hospital
that agrees to train residents who have been displaced by the closure
of another hospital's program may receive a temporary FTE cap
adjustment only if the hospital with the closed program(s)--
Temporarily reduces its FTE cap by the number of FTE
residents in each program year training in the program at the time of
the program s closure. The yearly reduction would be determined by
deducting the number of those residents who would have been training in
the program year during each year had the program not closed; and
No later than 60 days after the residents who were in the
closed program begin training at another hospital, submits to its
fiscal intermediary a statement signed and dated by its representative
that specifies that it agrees to the temporary reduction in its FTE cap
to allow the hospital training the displaced residents to obtain a
temporary adjustment to its cap; identifies the residents who were
training at the time of the program's closure; identifies the hospitals
to which the residents are transferring once the program closes; and
specifies the reduction for the applicable program years.
Unlike the closed hospital policy at Sec. 413.86(g)(8), we proposed
under this closed program policy (which we proposed to amend
Sec. 413.86(g)(8) to include), that in order for the receiving
hospital(s) to qualify for a temporary adjustment to its FTE cap, the
hospitals that are closing their programs would need to reduce their
FTE cap for the duration of time the displaced residents would need to
finish their training. We proposed this change because, as explained
below, the hospital that closes the program still has the FTE slots in
its cap, even if the hospital chooses not to fill the slots with
residents. We believe it is inappropriate to allow an increase to the
receiving hospital's cap without an attendant temporary decrease to the
cap of the hospital with the closed program, even if the increase is
only temporary. We noted that even under the proposed closed program
policy, the hospital that closes its program may choose instead to
affiliate with another hospital by July 1 of the next residency year so
that the residents can more easily finish their training.
We proposed that the cap reduction for the hospital with the closed
program would be based on the number of FTE residents in each program
year who were in the program at the program's closure, and who began
training at another hospital, rather than the count of residents each
year at the hospital(s) receiving the temporary adjustment(s). We
believe it would be too burdensome administratively to require the
hospital closing the program to keep track of the status of the
residents when they are training at other hospitals. For instance, Joe
Smith, a resident who is a PGY 1 when Hospital X closes its pathology
residency program, may then finish his training at Hospital Y. The
resident trains for one year at Hospital Y as a PGY 2, but decides to
drop out of the program before finishing. It would be burdensome to
require Hospital X to keep track of Joe Smith's status while he is
training at Hospital Y for purposes of the reduction in Hospital X's
cap. Therefore, we proposed to ``freeze'' the basis for the reduction
of the FTE cap of the hospital that closed the program based on the
count and status of the residents when the hospital closes the program.
Example: Hospital A, which has a direct GME FTE cap of 20 FTEs
and an IME FTE cap of 18 FTEs, is experiencing financial
difficulties and decides to close down its internal medicine
residency training program effective June 30, 2002. As of June 30,
2002, Hospital A is training 2 PGY 1s, 4 PGY 2s, and 6 PGY 3s in its
internal medicine program. Hospitals B, C, and D take on the
training of the displaced residents. These hospitals are eligible to
receive temporary adjustments to their FTE caps if they follow the
proposed criteria stated above. In order for Hospitals B, C, and D
to receive the temporary adjustments, however, Hospital A must agree
to reduce its FTE cap. According to the proposed criteria stated
above, Hospital A's reduction would be:
July 1, 2002 through June 30, 2003
Direct GME FTE cap: 14 FTEs, (20 FTEs cap--2 PGY 2s-4 PGY 3s)
IME FTE cap: 12 FTEs (18 FTEs-2 PGY 2s-4 PGY 3s)
We note that no downward adjustment for the 6 PGY 3s for either
cap is necessary since these residents will have completed their
training in that program by the July 1, 2000 through June 30, 2003
program year.
July 1, 2003 through June 30, 2004
Direct GME FTE cap: 18 FTEs (20 FTEs cap--2 PGY 3s)
IME FTE cap: 16 FTEs (18 FTEs cap--2 PGY 3s)
July 1, 2004 through June 30, 2005
Direct GME FTE cap: 20 FTEs
IME FTE cap: 18 FTEs
We also proposed to revise Sec. 412.105(f)(1)(ix) to make the
provision relating to the adjustment to FTE caps to reflect
residents affected by closure of hospitals' medical residency
training programs applicable to determining the IME payment.
Comment: Several commenters commended us for extending payment of
IME and direct GME to situations of program closure, explaining that
this change will help stabilize the GME system and ensure that
residents can continue their training without imposing financial
hardship on the institutions that accept them into their programs. One
commenter also noted that the tradeoff in the FTE resident cap between
a hospital closing its residency program and the hospital receiving the
displaced residents seems reasonable. Another commenter stated that
while the proposed rule more than adequately described the requirements
and procedures for allowing a hospital to receive a temporary
adjustment to its FTE caps to reflect residents added because of the
closure of another hospital's program, the receiving hospital is
penalized because the 3-year rolling average applies to these
residents. The commenter noted that, in the first and second year, the
receiving hospital will be paid one third and two thirds of the costs
of these displaced FTE residents because of the rolling average,
although the receiving hospital is paying for these FTE residents at
full cost. The commenter suggested that a temporary exception should be
granted to receiving hospitals from the 3-year rolling average in the
same manner as residents in new programs under Sec. 413.86(g)(5) are
excluded from the rolling average. The commenter also asked that
temporary relief should be granted in the IME adjustment with regard to
the application of the resident-to-bed ratio cap, wherein the relief
from this cap should be an adjustment to the prior year's resident FTEs
equal to the increase in the current year's FTEs which is attributable
to the transferred residents.
Response: We understand the commenter's concern regarding the
inclusion of the resident FTEs displaced by the closure of another
hospital's program in the receiving hospital's rolling average count of
residents, for both direct GME and IME purposes. In addition, we
believe that a similar concern also exists in regard to the inclusion
of residents in the receiving hospital's rolling average calculation
for residents displaced by the closure of another hospital. Therefore,
we are revising proposed Sec. 412.105(f)(1)(v) for IME and adding a
paragraph (vi) to proposed Sec. 413.86(g)(5) for direct GME to specify
that FTE residents that are displaced by the closure of either another
hospital or another hospital's program are added after the calculation
of the rolling average for the receiving
[[Page 39901]]
hospital for the duration of time that those displaced FTE residents
are training at the receiving hospital.
In regard to providing temporary relief to the receiving hospital's
IME resident-to-bed ratio cap for the displaced residents, while we
understand the commenter's concern about this issue as well, at this
time we have decided not to allow the exclusion of these displaced
residents in applying the resident-to-bed ratio cap. Under existing IME
policy, the receiving hospital may be held to a lower cap in the first
year of training the displaced residents. However, the receiving
hospital may benefit from the higher cap in the year following the
final year of the displaced residents' training. Effective in the first
year that the receiving hospital takes on the displaced residents, it
will be capped by the prior year's lower resident-to-bed ratio because
the displaced residents will not be included in the prior year FTE
count. However, an increase in the current year's ratio will establish
a higher cap for the following year. Furthermore, in the last year that
the receiving hospital is training the displaced residents, a higher
cap will be established for the following year in which all the
displaced residents will have left the hospital since they have
completed their training. Therefore, we believe it is unnecessary to
exclude displaced residents in applying the resident-to-bed ratio cap.
While we are not making any changes to address this issue at this time,
we will consider suggestions for possible changes in the future, if
warranted.
Comment: One commenter stated that it is unclear at what rate the
payments for IME and direct GME will be made for the hospital receiving
the displaced residents. The commenter asked if Medicare would pay that
hospital at the same rate that the hospital with the closed program was
paid for its residents, or would the receiving hospital receive
Medicare payment at the same rate it currently is paid.
Response: The receiving hospital will receive payment for the
displaced residents using its own rates--that is, the same rates as
those used for residents in its own programs. The receiving hospital
will use its own bed count for IME payment purposes, and its own PRA
and Medicare patient load for direct GME payment purposes.
Comment: One commenter stated that, although the commenter supports
the proposal for allowing temporary adjustments for residents coming
from a closed program, the commenter believed that a mechanism should
be established to ``permanently preserve resident positions, as opposed
to individual residents,'' so long as there is no increase in the total
number of FTE residents for which Medicare payment is made.
Response: In proposing Sec. 413.86(g)(8)(iii), which allows a
hospital to receive a temporary adjustment to its FTE caps to reflect
residents added because of the closure of another hospital's program,
we have attempted to make these regulations consistent with the
existing regulations at Sec. 413.86(g)(8). These existing regulations
allow a hospital to receive a temporary adjustment to its FTE caps to
reflect residents added because of the closure of another hospital.
Therefore, because the regulations only allow for a temporary cap
adjustment in situations involving hospital closure, we believe that it
is appropriate to only allow for a temporary adjustment in situations
involving program closure, as well.
6. Conforming Change to Regulations Governing Payment to Federally
Qualified Health Centers (Sec. 405.2468(f))
We have discovered a technical error in the regulations at
Sec. 405.2468(f) regarding payment to federally qualified health
centers (FQHCs) and rural health centers (RHCs) for the costs of
graduate medical education. Specifically, Sec. 405.2468(f)(6)(ii)(D)
provides that ``The costs associated with activities described in
Sec. 413.85(d) of this chapter'' are not allowable graduate medical
education costs. We recently amended Sec. 413.85 in a final rule (66 FR
3358, January 12, 2001) regarding Medicare pass-through payment for
approved nursing and allied health education programs. However, we
inadvertently did not make a conforming change to
Sec. 405.2468(f)(6)(ii)(D). Section 405.2468(f)(6)(ii)(D) should read
``The costs associated with activities described in Sec. 413.85(h) of
this chapter.'' We proposed to revise Sec. 405.2468(f)(6)(ii)(D) to
reflect this change.
7. Provisions of the August 1, 2000 Interim Final Rule With Comment
Period
The following provisions were included in the August 1, 2000
interim final rule with comment period. We are presenting a discussion
of these provisions here in order to respond to the public comments
received on the provisions and to finalize the rule.
Section 1886(h) of the Act, as revised by Public Law 105-33, caps
the number of residents a hospital may count for direct GME and IME. In
general, the total number of residents in the fields of allopathic or
osteopathic medicine in a hospital may not exceed the number of such
FTE residents in the hospital with respect to the hospital's most
recent cost reporting period ending on or before December 31, 1996. In
the regulations we published on August 29, 1997 (62 FR 46003), May 12,
1998 (63 FR 26327), July 31, 1998 (63 FR 40986), and July 30, 1999 (64
FR 41517), we established special rules for adjusting the FTE resident
caps for indirect and direct GME for new medical residency programs.
Public Law 106-113 further revised sections 1886(d) and 1886(h) of the
Act to allow a hospital's caps to be adjusted if certain additional
criteria are met.
a. Counting Primary Care Residents on Certain Approved Leaves of
Absence in Base-Year FTE Count (Section 407(a)(1) of Public Law 106-113
and New 42 CFR 412.105(f)(1)(xi) and 413.86(g)(9))
The limit that was placed on the number of residents that a
hospital may count for purposes of direct GME and IME is based on the
number of residents in the hospital's most recent cost reporting period
ending on or before December 31, 1996. In the situation where a primary
care resident was previously training in a hospital's residency
program, but was on an approved leave of absence during the hospital's
most recent cost reporting period ending on or before December 31,
1996, the hospital's FTE cap may be lower than it would have been had
the resident not been on an approved leave of absence. Section 407(a)
of Public Law 106-113 amended section 1886(h)(4)(F) of the Act to
direct the Secretary to count an individual for purposes of determining
a hospital's FTE cap, to the extent that the individual would have been
counted as a primary care resident for purposes of the FTE cap but for
the fact that the individual was on maternity or disability leave or a
similar approved leave of absence.
The statute allows a hospital to receive an adjustment for those
residents to its individual FTE cap of up to three additional FTE
residents. We provided that, in order for a hospital to receive this
adjustment, the leave of absence must have been approved by the
residency program director to allow the residents to be absent from the
program and return to the program after the absence. We required that
no later than 6 months after the date of publication of this interim
final rule, the hospital must submit a request to the fiscal
intermediary for an adjustment to its FTE cap and must provide
contemporaneous documentation of the approval of the leave of absence
by the residency program director, specific to
[[Page 39902]]
each additional resident that is to be counted for purposes of the
adjustment. For example, a letter to the resident by the residency
program director before the resident takes the leave would be
sufficient documentation of prior approval of the leave of absence.
Under section 407(a)(3) of Public Law 106-113, this provision is
effective for direct GME FTE counts with cost reporting periods
beginning on or after November 29, 1999, and for IME FTE counts, with
discharges occurring in cost reporting periods beginning on or after
November 29, 1999.
We added Secs. 412.105(f)(1)(xi) and 413.86(g)(9) to our
regulations to incorporate the provisions of section 407(a) of Public
Law 106-113.
We received one comment concerning section 407(a)(1) of Public Law
106-113, as implemented at Secs. 412.105(f)(1)(xi) and 413.86(g)(9),
concerning the counting of primary care residents in certain approved
leaves of absence in base-year FTE counts.
Comment: One commenter asked us to consider allowing hospitals to
count FTE residents for residents who had been training in an approved
residency program at a hospital but then left the hospital during the
1996 base-year and never returned. The commenter stated that the FTE
slot in which the ``abandoning'' resident vacated sometime in 1996 was
filled by another resident in 1997 and thereafter, but the hospital has
never received any direct or indirect GME payment for this FTE slot.
Response: Section 407(a) of Public Law 106-113 amended section
1886(h)(4)(F) of the Act to direct the Secretary to count an individual
for purposes of determining a hospital's FTE cap to the extent that the
individual would have been counted as a primary care resident for
purposes of the FTE cap but for the fact that the individual ``was on
maternity or disability leave or a similar approved leave of absence.''
We believe that this provision was not intended to apply to residents
who leave the program in the base-year and never return. The statutory
language is quite clear that in order for a hospital to count residents
in this provision, the resident must have been on an ``approved leave
of absence.'' A ``leave of absence'' necessarily translates to a
resident being away and then returning to the hospital at which the
resident had been training.
b. Adjustments to the FTE Cap for Rural Hospitals (Section 407(b)(1) of
Public Law 106-113 and 42 CFR 412.105(f)(l)(iv) and 413.86(g)(4))
Public Law 105-33 included several provisions with the intent of
encouraging physician training and practice in rural areas. Section
1886(h)(4)(H)(i) of the Act, as added by section 4623 of Public Law
105-33, directed the Secretary, in promulgating rules for the purpose
of the FTE cap, to give special consideration to facilities that meet
the needs of underserved rural areas. Consistent with the intent of
this provision, section 407(b) of Public Law 106-113 provides a 30-
percent expansion of a rural hospital's direct and indirect FTE count
for purposes of establishing the hospital's individual FTE cap.
Specifically, section 407(b) provided that, effective for direct GME
with cost reporting periods beginning on or after April 1, 2000, and
for IME, with discharges occurring on or after April 1, 2000, the FTE
count may equal 130 percent of the number of unweighted residents the
rural hospital counted in its most recent cost reporting period ending
on or before December 31, 1996.
For example, if a hospital located in a rural area had 10
unweighted FTEs for its count for both direct GME and IME in its most
recent cost reporting period ending on or before December 31, 1996,
under this new provision the hospital would have a FTE cap of 13
unweighted FTEs, instead of 10 unweighted FTEs, because the hospital is
located in a rural area. The revised FTE cap is equal to 130 percent of
the number of unweighted residents in its most recent cost reporting
period ending on or before December 31, 1996. The rural hospital's new
FTE cap, effective April 1, 2000, is now 13 FTEs. However, if a
hospital located in a rural area had zero unweighted FTEs for its count
for both direct GME and IME in its most recent cost reporting period
ending on or before December 31, 1996, under this new provision, this
hospital would receive no adjustment to its FTE cap (130 percent of
zero is zero FTEs).
We incorporated the provision of section 407(b) of Public Law 106-
113 in Secs. 412.105(f)(1)(iv) and 413.86(g)(4). We did not receive any
comments on this provision.
c. Rural Track FTE Limitation for Purposes of GME and IME for Urban
Hospitals that Establish Separately Accredited Approved Medical
Programs in a Rural Area (Section 407(c) of Public Law 106-113 and new
42 CFR 412.105(f)(1)(x) and 413.86(g)(11))
In order to encourage the training of physicians in rural areas,
section 407(c) of Public Law 106-113 amended section 1886(h)(4)(H) of
the Act to add a provision that in the case of a hospital that is not
located in a rural area but establishes separately accredited approved
medical residency training programs (or rural tracks) in a rural area
or has an accredited training program with an integrated rural track,
an adjustment may be made to the hospital's cap on the number of
residents. For direct GME, the amendment applies to payments to
hospitals for cost reporting periods beginning on or after April 1,
2000; for IME, the amendment applies to discharges occurring on or
after April l, 2000.
Section 407(c) of Public Law 106-113 did not define ``rural
tracks'' or an ``integrated rural track,'' nor are these terms defined
elsewhere in the Social Security Act or in any applicable Federal
regulations. Currently, there are a number of accredited residency
programs, particularly 3-year primary care residency programs, in which
residents train for 1 year of the program at an urban hospital and are
then rotated for training for the other 2 years of the 3-year program
to a rural facility. These separately accredited ``rural track''
programs are identified by the Accreditation Council of Graduate
Medical Education (ACGME) as ``1-2'' rural track programs. Accordingly,
we implemented section 407(c) to address these ``1-2'' programs. In
addition, we implemented section 407(c) to account for other programs
that are not ``1-2'' programs but which include rural training
portions.
As stated above, since there is no existing definition of ``rural
track'' or ``integrated rural track,'' we defined at Sec. 413.86(b) a
``rural track'' and an ``integrated rural track'' as an approved
medical residency training program established by an urban hospital in
which residents train for a portion of the program at the urban
hospital and then rotate for a portion of the program to a rural
hospital(s) or to a rural nonhospital site(s). We noted that ``rural
track'' and ``integrated rural track,'' for purposes of this
definition, are synonymous.
We amended Sec. 413.86 to add paragraph (g)(11) (and amended
Sec. 412.105 to add paragraph (f)(1)(x)) to specify that, for direct
GME, for cost reporting periods beginning on or after April 1, 2000,
(or, for IME, for discharges occurring on or after April 1, 2000), an
urban hospital that establishes a new residency program, or has an
existing residency program, with a rural track (or an integrated rural
track) may include in its FTE count residents in those rural tracks, in
addition to the residents subject to the FTE cap at Sec. 413.86(g)(4).
An urban hospital may count the residents in the rural track up to a
``rural track FTE limitation'' for that
[[Page 39903]]
hospital. We defined this rural track FTE limitation at Sec. 413.86(b)
as the maximum number of residents training in a rural track residency
program that an urban hospital may include in its FTE count, that is in
addition to the number of FTE residents already included in the
hospital's FTE cap.
Generally, the rural track policy is divided into two categories:
Rural track programs in which residents are rotated to a rural area for
at least two-thirds of the duration of the program; and rural track
programs in which residents are rotated to a rural area for less than
two-thirds of the duration of the program. These two categories are
then subdivided according to where the residents are training in the
rural area; the residents may be trained in a rural hospital or the
residents may be trained in a rural nonhospital site. To account for
rural track residency programs with rural rotations that have program
lengths greater than or less than 3 years, or that are not ``1-2''
programs, we specified ``two-thirds of the length of the program,''
instead of ``2 out of 3 program years,'' as a qualification to count
FTEs in the rural track.
In the interim final rule with comment period, we specified that
urban hospitals that wish to count FTE residents in rural tracks, up to
a rural track FTE limitation, must comply with the conditions discussed
below:
(1) Rotating Residents for at Least Two-Thirds of the Program to a
Rural Hospital(s)
In the August 1, 2000 interim final rule with comment period, we
specified at Sec. 413.86(g)(11)(i) that if an urban hospital rotates
residents in the rural track program to a rural hospital(s) for at
least two-thirds of the duration of the program, the urban hospital may
include those residents in its FTE count for the time the rural track
residents spend at the urban hospital. The urban hospital may include
in its FTE count those residents in the rural track training at the
urban hospital, not to exceed its rural track FTE limitation,
determined as follows:
For the first 3 years of the rural track's existence, the
rural track FTE limitation for each urban hospital will be the actual
number of FTE residents training in the rural track at the urban
hospital.
Beginning with the fourth year of the rural track's
existence, the rural track FTE limitation is equal to the product of:
(1) The highest number of residents in any program year who, during the
third year of the rural track's existence, are training in the rural
track at the urban hospital or the rural hospital(s) and are designated
at the beginning of their training to be rotated to the rural
hospital(s) for at least two-thirds of the duration of the program; and
(2) the number of years those residents are training at the urban
hospital.
We utilized the term ``designated'' at Sec. 413.86(g)(11)(i) (as
well as at Secs. 413.86(g)(11)(ii) and (iv)) to refer to the
calculation of the rural track FTE limitation. ``Designated'' means
that the residents must actually have enrolled in that rural track
program to rotate for a portion of the rural track program to a rural
area (either rural hospital(s) or rural nonhospital site(s)). To be
counted as an FTE in this first scenario, these enrolled residents must
actually rotate for at least two-thirds of the duration of the program
to a rural hospital(s). If a resident, at the beginning of his or her
training, intends to train in the rural area for at least two-thirds of
the duration of the program, but ultimately never does so, this
resident would be proportionately excluded from the urban hospital's
rural track FTE limitation.
We noted that if the residents in the rural track are rotating to a
rural hospital(s), the rural hospital(s) may be eligible to count the
residents as part of its FTE count. If the rural track residency
program is a new residency program as specified in redesignated
Sec. 413.86(g)(12), the rural hospital may be eligible to receive an
FTE cap adjustment for those residents training in the rural track for
the time those residents are training at the rural hospital(s), in
accordance with the provisions of existing Sec. 413.86(g)(6)(iii). If
the rural track residency program is an existing residency program, a
rural hospital may be eligible to count the FTE residents training in
the rural track at the rural hospital(s), in accordance with the
provisions of Sec. 413.86(g)(4), as amended in the interim final rule
with comment period to implement section 407(b)(1) of Public Law 106-
113.
(2) Rotating Residents for at Least Two-Thirds of the Program to a
Rural Nonhospital Site
In the August 1, 2000 interim final rule with comment period, we
specified at Sec. 413.86(g)(11)(ii) that if an urban hospital rotates
residents in the rural track program to a rural nonhospital site(s) for
at least two-thirds of the duration of the program, the urban hospital
may include those residents in its FTE count, subject to the
requirements under existing Sec. 413.86(f)(4). The urban hospital may
include in its FTE count those residents in the rural track, not to
exceed its rural track FTE limitation, determined as follows:
For the first 3 years of the rural track's existence, the
rural track FTE limitation for each urban hospital will be the actual
number of FTE residents training in the rural track at the urban
hospital and the rural nonhospital site.
Beginning with the fourth year of the rural track's
existence, the rural track FTE limitation is equal to the product of:
(1) The highest number of residents in any program year who, during the
third year of the rural track's existence, are training in the rural
track at the urban hospital and are designated at the beginning of
their training to be rotated to a rural nonhospital site(s) for at
least two-thirds of the duration of the program and the rural
nonhospital site(s); and,(2) the number of years in which the residents
are expected to complete each program based on the minimum accredited
length for the type of program.
We note that we specified at Sec. 413.86(g)(11)(ii) that an urban
hospital may include in its FTE count those residents in the rural
track rotating to a rural nonhospital site, subject to the requirements
under existing Sec. 413.86(f)(4). Section 413.86(f)(4) provides, in
part, that a hospital that incurs ``all or substantially all'' of the
costs of training residents in a nonhospital site may include those
residents in determining the number of FTE residents (not to exceed the
FTE cap) for that hospital. Under this rural track policy, where the
urban hospital rotates residents for at least two-thirds of the
residency program to a rural nonhospital site, the urban hospital would
be eligible to include in its FTE count residents training in the rural
track up to its rural track FTE limitation, but the urban hospital must
still reimburse the rural nonhospital site for the costs of training
those residents, as specified under Sec. 413.86(f)(4). In the August 1,
2000 interim final rule with comment period (66 FR 47034), we included
an example of application of this policy.
(3) Rotating Residents for Less Than Two-Thirds of the Program to a
Rural Hospital(s)
In the August 1, 2000 interim final rule with comment period, we
specified at Sec. 413.86(g)(11)(iii) that if an urban hospital rotates
residents in the rural track program to a rural hospital(s) for periods
of time that are less than two-thirds of the duration of the program,
the urban hospital may not include those residents in its FTE count,
nor may the urban hospital include those residents as part of its rural
track FTE
[[Page 39904]]
limitation. However, we noted that, in this scenario, if the rural
track residency program is a new residency program as specified in
redesignated Sec. 413.86(g)(12), the rural hospital may be eligible to
receive an FTE cap adjustment for those residents training in the rural
track, in accordance with the provisions of existing
Sec. 413.86(g)(6)(iii). If the rural track residency program is an
existing residency program, a rural hospital may count the FTE
residents training in the rural track at the rural hospital(s), in
accordance with the provisions of Sec. 413.86(g)(4), as amended, to
incorporate the provisions of section 407(b)(1) of Public Law 106-113.
We are not permitting an urban hospital to count the time of
residents training at the urban hospital in a rural track rotating to a
rural hospital(s) for less than two-thirds the duration of the program
(either as part of the urban hospital's FTE count or as part of its
rural track FTE limitation), because to do so would inappropriately
allow the urban hospital to circumvent the FTE caps by creating a new
program with minimal training in a rural track. However, in this
situation, like the other three provisions that concern the training of
residents in rural areas, we indicated that we will allow Medicare
payment for the rural portion of the training to the rural hospital.
(4) Rotating Residents for Less Than Two-Thirds of the Program to a
Rural Nonhospital Site
In the August 1, 2000 interim final rule with comment period, we
specified at Sec. 413.86(g)(11)(iv) that if an urban hospital rotates
residents in the rural track program to a rural nonhospital site(s) for
periods of time that are less than two-thirds of the duration of the
program, the urban hospital may include those residents in its FTE
count, subject to the requirements under existing Sec. 413.86(f)(4).
The urban hospital may include in its FTE count those residents in the
rural track, not to exceed its rural track FTE limitation, determined
as follows:
For the first 3 years of the rural track's existence, the
rural track FTE limitation for the urban hospital will be the actual
number of FTE residents training in the rural track at the rural
nonhospital site.
Beginning with the fourth year of the rural track's
existence, the rural track FTE limitation is equal to the product of:
(a) The highest number of residents in any program year who, during the
third year of the rural track's existence, are training in the rural
track at the rural nonhospital site(s); and (b) the length of time in
which the residents are being trained at the rural nonhospital site(s).
We noted that, in this situation, an urban hospital would not be
able to count the FTE for the rural track resident while the resident
is training at the urban hospital. The rural track FTE count and the
rural track FTE limitation for the urban hospital would be limited to
account for the residents training at the rural nonhospital site.
As in the second scenario at Sec. 413.86(g)(11)(ii), we specified
at Sec. 413.86(g)(11)(iv) that an urban hospital may include in its FTE
count those residents in the rural track rotating to a rural
nonhospital site, subject to the requirements under Sec. 413.86(f)(4).
Under the rural track policy, where the urban hospital rotates
residents for less than two-thirds of the residency program to a rural
nonhospital site, the urban hospital would be eligible to include in
its FTE count residents training in the rural track up to its rural
track FTE limitation, but the urban hospital must still reimburse the
rural nonhospital site for the costs of training those residents, as
specified under Sec. 413.86(f)(4).
We noted that, in this last scenario, we are allowing the urban
hospital to receive a rural track FTE limitation even in situations
where it is rotating residents to a rural area for a minimal period of
time (less than two-thirds the duration of the program). However, we
believe that this last scenario can be distinguished from the third
scenario in which the urban hospital is again rotating residents to a
rural area for a minimal portion of the program but to a rural hospital
instead of a rural nonhospital site. In the third scenario, we allow
Medicare payment to go to the rural hospital for the portion of the
urban hospital program that involves rural training (but not to the
urban hospital, if the rural hospital is receiving an FTE cap
adjustment for that training). However, in the last scenario, we allow
the urban hospital to include the rural track residents in its FTE
count (and as part of its rural track FTE limitation), based on how
long it rotates the residents to the rural nonhospital site (and also
incurs all or substantially all of the training costs). We do not
believe that the urban hospital can circumvent its FTE cap in this last
scenario because it will only count the rural track residents based on
the portion of training in the rural nonhospital site. In the interim
final rule with comment period (66 FR 47035), we included an example of
the last scenario.
(5) Conditions That Apply to All Urban Hospitals
In the August 1, 2000 interim final rule with comment period, we
specified that all urban hospitals that wish to count FTE residents in
rural tracks, not to exceed their respective rural track FTE
limitations, must also comply with each of the following conditions, as
stated at Secs. 413.86(g)(11)(v) and (vi):
A hospital may not include in its FTE count residents who
are training in a rural track residency program that were already
included as part of the hospital's FTE cap (if the rural track program
was in existence during the hospital's most recent cost reporting
period ending on or before FY 1996).
A hospital must base its count of residents in a rural
track on written contemporaneous documentation that each resident
enrolled in a rural track program at the urban hospital intends to
rotate for a portion of the residency program to a rural area. For
example, written contemporaneous documentation might be a letter of
intent signed and dated by the rural track residency program director
and the resident at the time of the resident's entrance into the rural
track program as a PGY 1.
All residents who are included by the hospital as part of
its FTE count (not to exceed its rural track FTE limitation) must
ultimately train in the rural area.
If we find that residents who are included by the urban
hospital as part of its FTE count did not actually complete the
training in the rural area, we will reopen the urban hospital's cost
report within the 3-year reopening period (as specified in
Sec. 405.1885) and adjust the hospital's Medicare GME payments (and,
where applicable, the hospital's rural track FTE limitation).
We received several comments regarding the provisions of section
407 of Public Law 106-113 implemented in the August 1, 2000 interim
final rule with comment period.
Comment: One commenter cited studies that found that more than half
of residents with as little as 3 months of rural training became rural
physicians, and, therefore, to best serve the intent of the legislation
and significantly increase the number of rural physicians, we should
fully fund FTEs with less than two-thirds total training in rural
areas.
Response: Section 1886(h)(4)(H)(iv) of the Act, as added by section
407(c) of Public Law 106-113, provides for adjustments to the FTE cap
``[i]n the case of a hospital that is not located in a rural area but
establishes separately accredited approved medical residency training
programs (or rural tracks) in a[]
[[Page 39905]]
rural area * * *.'' Thus, in order for a hospital to receive an
adjustment under this provision, the training program must be
separately accredited. The ACGME has established criteria to separately
accredit programs that involve training in rural areas; under these
criteria, a training program may be separately accredited if residents
in the program train for at least 2 years of the 3-year program at a
rural facility. Currently, the ACGME does not separately accredit a
program as a rural track program or a program in a rural area unless it
meets this ``1-2'' condition. We make an adjustment to the FTE cap
under the rural track provision only if a program is separately
accredited, and in order to be separately accredited, the program must
meet ACGME's ``1-2'' criteria. We are amending the regulations at
Sec. 413.86 by adding paragraph (g)(11) to reflect this policy .
Furthermore, we believe that incorporating the ACGME's criteria
reasonably identifies the situations in which an adjustment to the FTE
cap under the rural track provision is warranted. We believe that it is
important to limit adjustments under this provision to situations in
which residents receive a significant amount of training in rural
areas. While we certainly agree that post-residency physician retention
in rural areas is important, we believe that it is also important to
prevent hospitals from receiving adjustments to the FTE cap in
situations when an adjustment is not warranted. We believe that, if an
urban hospital could receive an adjustment to its FTE cap by providing
only a nominal amount of training in a rural area, then hospitals might
be able to inappropriately circumvent the FTE caps. Thus, our policy
reflects the requirements of the statute as well as a balancing of
considerations (permitting adjustments for hospitals that establish
programs that provide a significant amount of training in rural areas,
and preventing adjustments for hospitals that do not warrant an
adjustment).
Comment: One commenter noted that, for cost reporting periods
beginning on or after April 1, 2000, section 407 of Public Law 106-113
allows rural hospitals to increase their FTE resident caps by 30
percent and urban hospitals with rural training tracks to count those
residents in rural tracks. The commenter had two concerns: (1) What
happens to rural track programs that were in existence between January
1, 1997 and April 1, 2000; and (2) if the intent of the rural track
provision is to encourage training in rural areas, then rural track
programs in existence between January 1, 1997 and April 1, 2000 should
also be permitted to expand by 30 percent.
Response: Section 1886(h)(4)(F) of the Act, as added by section
407(b) of Public Law 106-113, and as implemented at Secs. 413.86(g)(4)
and 412.105(f)(1)(iv), provides for a 30-percent expansion to a rural
hospital's direct and indirect FTE counts for purposes of establishing
the hospital's individual FTE cap. Section 407(c) provides for an
adjustment to the FTE cap of urban hospitals for training residents in
rural areas. Section 407(b) clearly only applies to rural hospitals,
and not to urban hospitals, regardless of whether or not the urban
hospitals train residents in rural areas. Therefore, while the general
intent of the provisions at section 407 is to encourage training in
rural areas, only those rural hospitals that have a FTE resident cap
based on the count of residents in the hospital's cost reporting period
ending on or before December 31, 1996, may qualify for a 30-percent
increase to that FTE cap under the amendments made by section 407(b).
To address the commenter's uncertainty concerning what happens to
rural track programs that were in existence between January 1, 1997 and
April 1, 2000, we point to our language at Secs. 413.86(g)(11) and
412.105(f)(1)(x) which states that for cost reporting periods beginning
on or after April 1, 2000, ``an urban hospital that establishes a new
residency program, or has an existing residency program, with a rural
track (or an integrated rural track) may include in its FTE count
residents in those tracks * * *'' (emphasis added). Thus, urban
hospitals with rural tracks that were in existence between January 1,
1997 and April 1, 2000, and continue to be in existence afterApril 1,
2000, may be eligible for Medicare payment under this provision. We
note that urban hospitals with rural tracks that were established
before January 1, 1997, and continued to exist after April 1, 2000, may
be eligible for payment under this rural track provision, as well.
We note that we have received questions from the provider industry
regarding the application of the rural track FTE limitation and rural
track FTE count to hospitals with rural track programs that have
already been in existence before April 1, 2000. Generally, the
methodology at Sec. 413.86(g)(11) states that the actual count of
residents for the first 3 years of the rural track's existence is to be
used as the hospital's rural track FTE limitation, and beginning with
the fourth year, the rural track FTE limitation is determined based on
the number of residents training in the rural track in the third year
of the program's existence. However, if a rural track program has been
in existence for at least 3 years prior to April 1, 2000, the provision
regarding using the actual count of residents in the first 3 years of
the program would not apply. Rather, for such a program, the rural
track FTE limitation would take effect immediately on April 1, 2000.
The limitation would be based on the highest number of residents in any
program year training in the rural track in the third year of the
program, depending on the amount of time the residents spent in the
rural area, subject to the regulations at Sec. 413.85(g)(11)(i) through
(iv). It would be the responsibility of the hospital to provide the
necessary information regarding the third year of the program to the
fiscal intermediary. For example, if the third year of the rural
track's existence is July 1, 1997 to June 30, 1998, the rural track FTE
limitation would be based on the highest number of residents in any
program year in 1997-1998 training year. The urban hospital may begin
to count the additional FTEs up to its rural track FTE limitation in
its cost reporting period beginning on or after April 1, 2000 for
direct GME, and for discharges occurring on or after April 1, 2000 for
IME.
Comment: One commenter noted that the interim final rule with
comment period states that ``all residents that are included by the
hospital as part of its FTE count must ultimately train in the rural
area.'' The commenter expressed concern that we are requiring hospitals
to designate specific individuals, rather than FTEs, and that basing
payment on individuals rather than FTEs would set a poor precedent. The
commenter further stated that, while specific individuals may not
remain in a program, hospitals should be permitted to fill these slots
with FTEs and receive payment.
Response: The commenter is concerned with the provision at
Sec. 413.86(g)(11)(v)(C), which states that all residents that are
included by the hospital as part of its FTE count under this provision
must ultimately train in the rural area. As the commenter correctly
assesses, this particular provision would link the rural track policy
to specific individual residents, rather than FTEs. We made this link
to individuals rather than FTEs because we believe the additional
provision at Sec. 413.86(g)(11)(v)(C) (as well as the provision at
Secs. 413.86(g)(11)(v)(B)) was necessary in order to ensure that urban
hospitals did not count additional FTE
[[Page 39906]]
residents who did not actually rotate at any time to a rural area.
However, we understand the commenter's concern about permitting
hospitals to fill slots with FTEs that are open because individuals did
not remain in the program. We agree that where a hospital fills a
vacated FTE slot in a rural 1-2 program with another resident, it would
be consistent with the intent of the rural track provision to allow the
urban hospital to count the time of the resident who left the training
program. Accordingly, we are amending the regulations at
Sec. 413.86(g)(11)(v)(C) to allow for the counting of the resident's
time at the urban hospital where, for example, a resident who just
completed her PGY1 year at the urban hospital decides to drop out of
the program, and then the urban hospital fills the vacated FTE slot
with another PGY2 resident who then continues and completes the rural
portion of the rural track program. We note that we would not allow for
the counting of the time at the urban hospital for the first year of
training for that resident who left the program where the urban
hospital fills the vacated FTE slot with another PGY1 resident who
first begins to train in the urban hospital, since, in effect, this
would result in double counting one FTE at the urban hospital without
the required amount of training occurring in the rural area.
Comment: One commenter expressed concern with the provision at
Sec. 413.86(g)(11)(v)(A) that states ``an urban hospital may not
include in its rural track FTE limitation or FTE count residents who
are training in a rural track residency program that were already
included as part of the hospital's FTE cap.'' The commenter stated that
this provision fails to account for the fact that many hospitals may
have ``backed out'' residents training time in rural sites from their
base year FTE cost reports. The commenter stated further that this
provision may be interpreted by cost report accountants to mean that
appeals to include FTEs that were excluded by Public Law 105-33 are
prohibited.
Response: We believe the commenter is confusing the provision at
Sec. 413.86(g)(11)(v)(A), that an urban hospital may not include in its
rural track FTE limitation or rural track FTE count residents who are
training in a rural track residency program that were already included
as part of the hospital's FTE cap, and the policy contained in section
4623 of Public Law 105-33, as implemented at Secs. 412.105(f)(1)(iv)
and 413.86(g)(4), which places a limit on the count of residents, or
hospitals' FTE caps. The intent of the provision at
Sec. 413.86(g)(11)(v)(A) is to encourage more residency training in
rural areas by providing for Medicare payment to an urban hospital for
FTE residents who are training in a rural area and are not already
included as part of the hospital's FTE cap. Whether or not there are
many hospitals that have ``backed out'' resident training time in rural
sites from their base year FTE cost reports is irrelevant to this rural
track requirement. The possible mistaken exclusion of the count of
resident FTEs spent in rural settings is an issue relevant to the
determination of a hospital's initial FTE cap as provided for at
Secs. 412.105(f)(1)(iv) and 413.86(g)(4). The rural track requirement
at Sec. 413.86(g)(11)(v)(A) was not intended to provide for adjustments
to reflect FTEs that were excluded from the FTE cap.
With regard to rural training, generally, and the determination of
a hospital's FTE cap under Secs. 412.105(f)(1)(iv) and 413.86(g)(4), a
FTE resident should not have been included in the hospital's FTE cap to
the extent that, in that cost reporting year, the resident was rotating
to another rural hospital, or if the resident was rotating to a rural
nonhospital to which the urban hospital was not paying all or
substantially all of the costs of training (see Sec. 413.86(f)(3)).
To clarify the intent of the requirement that ``an urban hospital
may not include in its rural track FTE limitation or FTE count
residents who are training in a rural track residency program that were
already included as part of the hospital's FTE cap,'' we are providing
the following example:
Assume there are 10 unweighted FTE residents training at
an urban Hospital A in the hospital's most recent cost reporting period
ending on or before December 31, 1996, thereby establishing Hospital
A's FTE cap at 10.
In July 2002, Hospital A starts a rural training track
program. In addition to devoting 2 out of its 10 FTE slots to the rural
track, Hospital A recruits an additional 2 FTEs to participate in the
rural track, for a total of 12 FTEs to be trained in that cost
reporting year.
These 4 FTEs will complete 1 year of training at Hospital
A and 2 years of training at a rural nonhospital site. This type of
program is modeled after the scenario outlined at
Sec. 413.86(g)(11)(ii), where the urban hospital may include in its FTE
count the FTEs in the rural track at the urban hospital and at the
rural nonhospital site. (Hospital A is complying with the requirements
at Sec. 413.86(f)(4) regarding the counting of residents in nonhospital
sites).
However, when calculating the rural track FTE limitation in the
fourth year of the rural track's existence, Hospital A may not include
in its rural track FTE limitation those FTEs that were already included
as part of the hospital's initial FTE cap. Two of the hospital's four
FTEs training in the rural track were already included in the
hospital's FTE cap. Therefore, beginning July 2002, only two FTEs may
be included to determine the hospital's rural track FTE limitation, as
well as its rural track FTE count. Since it is the two FTEs that
Hospital A added when it started the rural track that have caused the
hospital to exceed its FTE cap, only two FTEs may be counted above the
FTE cap for the hospital's rural track FTE count and limitation.
However, we note that the other two FTEs training in the rural track
that were not included as part of the hospital's rural FTE count and
limitation because they had already been included as part of the
hospital's FTE cap, may still be counted by the hospital in its general
FTE count, according to Secs. 412.105(f) and 413.86(f).
Comment: One commenter requested that, since rural hospitals often
do not have the resources or infrastructure to claim their GME costs on
a Medicare cost report, we should revise the regulations to allow urban
hospitals to claim the resident FTEs training at the rural hospitals,
as long as the urban hospitals are providing ``adequate funding'' to
the rural hospital, similar to our Medicare policy on nonhospital
settings.
Response: In regard to the request to allow urban hospitals to
claim the FTEs training in rural hospitals, while we understand that it
is not uncommon for urban hospitals to incur the costs of training
residents in rural hospitals because the rural hospitals cannot incur
the costs themselves, there is longstanding policy that prohibits one
hospital from claiming the training time of FTEs training at another
hospital. First, section 1886(h)(4)(B) of the Act states that the rules
governing the direct GME computation of count of the number of FTE
residents ``shall take into account individuals who serve as residents
for only a portion of a period with a hospital or simultaneously with
more than one hospital.'' Accordingly, the September 4, 1990 Federal
Register (55 FR 36065) states that ``* * * the other hospital is
required to include the portion of time the resident spent at its
facility in its FTE count consistent with Sec. 413.86(f).'' Further,
the regulations at Sec. 413.86(f)(2) state that ``No individual may be
counted as more than one FTE * * *. [I]f a resident spends time in more
than one hospital * * * the
[[Page 39907]]
resident counts as partial FTE based on the proportion of time worked
at the hospital to the total time worked * * *.'' Therefore, even
though the urban hospital incurs the training costs and the rural
hospital does not claim the FTEs for Medicare direct GME and IME
payment purposes, the urban hospital is precluded from claiming any
FTEs training at the rural hospital (or any other hospital, for that
matter). The commenter is correct in stating that a hospital may count
the time residents spend in nonhospital settings if they comply with
the criteria at Sec. 413.86(f)(4). However, this regulation implements
statutory provisions (sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of
the Act), which specifically provide for Medicare direct GME and IME
payment to be made to hospitals for training residents in nonhospital
settings.
Comment: One commenter objected to the policy in the interim final
rule with comment period that the terms ``rural track'' and
``integrated rural track'' are synonymous. The commenter (a hospital)
believed that we have the authority to develop a new definition for
``integrated rural track'' based on our interpretations of
congressional intent, and we should not wait for further clarification
from Congress at the expense of the commenter's particular allopathic
family practice residency program. The commenter described this program
as one in which the residents train in the rural setting for
approximately 7 months out of a 3-year program, and for the remainder
of the program when the residents spend training in the urban setting,
the residents treat rural patients. The commenter proposed the
following new definition for integrated rural track: ``Accredited
Training Program with an Integrated Rural Track--refers to an
accredited program that provides at least 6 months of training at a
rural location in addition to 2 years of rural training at an urban
location. The 6 months of rural training should be conducted as part of
all 3 years of training. The program should also establish a continuity
of care with patients in a rural area for at least one program year.''
Response: When we implemented this provision on August 1, 2000, we
did so based on discussions with the Accreditation Council for Graduate
Medical Education (ACGME), which accredits rural track programs. The
ACGME specifically identifies and separately accredits programs with 1
year of training in an urban hospital and 2 years of training in a
rural facility as ``rural tracks.'' However, the ACGME explained that
it did not have a separate definition of ``integrated rural track''
and, in particular, did not separately classify programs with portions
of rural training of less than 2 years as ``integrated rural tracks''.
In response to questions raised on this provision, we have followed up
with the ACGME to confirm whether a definition of, or criteria for
identifying programs with, ``integrated rural tracks'' had been
established. We were informed that the term ``integrated rural track''
is not, and never was, a term that is used by the ACGME in accrediting
its programs. Other than the 1-2 programs that specifically incorporate
2 years of rural training, the ACGME does not grant unique
accreditation to programs with a rural focus, nor do any of the other
accreditation organizations listed at Sec. 415.152.
In addition, we do not believe it is administratively feasible for
us to review documentation and confirm that the training at the urban
hospital, as suggested by the commenter, is rural in nature, based on
the patient load treated by the residents at the urban hospital. We
currently do not have a way of tying patient data to the residents that
treat them. Accordingly, for purposes of this policy, until we believe
we can appropriately categorize and define rural tracks and integrated
rural tracks separately, we will continue to define these terms
synonymously. We remain open to adopting another definition of a
separately accredited training program, and we welcome suggestions for
definitions that would be administratively feasible to apply.
Comment: One commenter suggested that we add a fifth scenario to
those already described at Sec. 413.86(g)(11). The commenter proposed
the following regulation text:
Rotating Residents of an Accredited Training Program with an
Integrated Rural Track to a Rural Nonhospital Site--If an urban
hospital rotates residents in an accredited training program with an
integrated rural track to a rural nonhospital site throughout all 3
years of training, the urban hospital may include those residents in
its FTE count, subject to the requirements under existing
Sec. 413.86(g)(4). The urban hospital may include in its FTE count
those residents in the rural track, not to exceed its rural track
FTE limitation, determined as follows:
(A) For the first 3 years of the integrated rural track's
existence, the rural track FTE limitation for each urban hospital
will be the actual number of FTE residents training in the rural
track at the urban hospital and the rural nonhospital site.
(B) Beginning with the fourth year of the integrated rural
track's existence, the rural track FTE limitation is equal to the
product of:
(1) The highest number of residents in any program year who,
during the third year of the integrated rural track's existence, are
training in the integrated rural track at the urban hospital and are
designated at the beginning of their training to be rotated to a
rural nonhospital site throughout all 3 years of training, and
(2) The number of years in which the residents are expected to
complete each program based on the minimum accredited length for the
type of program.
(C) This would apply to accredited training programs with
integrated rural tracks that were in existence prior to 1997.
The commenter explained that this language is designed to address
the unique program at the commenter's hospital, and it also is date
sensitive so that newer programs would be required to comply with the
existing criteria in the existing regulations.
Response: We have concerns about the commenter's proposal. First,
the commenter assumes a separate definition of ``integrated rural
track,'' which, as explained above, we currently do not have. Even if
we were to adopt such a change in policy, the cut-off date of 1997 in
paragraph (C) of the commenter's proposed changes seems arbitrary;
there is nothing in the statute that would serve as a basis to simply
grandfather existing ``integrated rural track'' programs and not
provide for new ones post-1997. Accordingly, we are not adopting such a
change in our rural track policy as the one described by the commenter.
Comment: One commenter thought that if a hospital's rural track
program has been in existence since 1993, then the 4th program year is
1997. The commenter explained that when the FTE cap went into effect,
the hospital was capped at 15 FTEs. The hospital subsequently added
another three residents at its own expense. The commenter stated that
it interprets Sec. 413.86(g)(11)(v)(A) to mean that the hospital would
only be able to count the additional three FTE residents for the rural
track count. The commenter urged us to reconsider this language as it
relates to hospitals with only one residency program, because the
commenter was unsure whether or not all the residents in the program
count toward the rural track FTE count. The commenter believed that for
hospitals with only one residency program that existed prior to 1996,
all rural track residents included in the original hospital FTE cap
should be counted toward the rural FTE count.
Response: The commenter correctly interprets the intent of the
regulation at Sec. 413.86(g)(11)(v)(A), which states that only those
FTEs in the rural track that were not already counted as part of the
[[Page 39908]]
hospital's FTE cap may be considered when calculating the hospital's
rural track FTE limitation and count. In the scenario the commenter
outlined above, if the first program year of the rural track program
began on July 1, 1993, then the fourth program year would begin on July
1, 1996, not in 1997. Because 15 FTEs were already included in the
hospital's FTE cap, assuming the urban hospital qualifies to count the
FTEs, only 3 out of the 18 FTE residents training in the program may be
considered in determining the hospital's rural track FTE limitation and
counts (the specific rural FTE limitation and count are dependent upon
which scenario the hospital's program fits under Sec. 413.86(g)(11)).
We do not believe it is necessary to revise this policy for
hospitals whose only GME program is the rural track program that was in
existence prior to 1996, as the commenter suggested. Hospitals that had
rural track programs in existence in 1996 were able to count those
residents training at the urban hospital at that time as part of their
initial FTE caps. Our existing policy on rural tracks at
Sec. 413.86(g)(11) provides additional assistance to these hospitals by
allowing them to count separately in their rural track FTE limitations,
FTE residents not included in the FTE cap but participating in a rural
track.
Accordingly, we are adopting the provisions in the August 1, 2000
interim final rule with comment period implementing section 407(c) of
Public Law 106-113 as final.
In addition, we are making a technical correction. The regulations
at Sec. 413.86(g)(6) currently state, ``If a hospital established a new
medical residency training program as defined in paragraph (g)(9) of
this section * * *.'' When we revised the regulations at
Sec. 413.86(g)(9) to redesignate the paragraph as Sec. 413.86(g)(12) in
the August 1, interim final rule with comment period, we inadvertently
did not make a corresponding revision at Sec. 413.86(g)(6). Therefore,
we are revising Sec. 413.86(g)(6) to read ``If a hospital established a
new medical residency training program as defined in paragraph (g)(12)
of this section * * *'' We are making the same revision to the
regulations for IME at Sec. 412.105(f)(vii).
d. Not Counting Against Numerical Limitation Certain Residents
Transferred from a Department of Veterans AffairsHospital's Residency
Program That Loses Accreditation(Section 407(d) of Public Law 106-113
and new 42 CFR 412.105(f)(1)(xii) and 413.86(g)(10))
Section 407(d) of Public Law 106-113 addressed the situation where
residents were training in a residency training program at a Veterans
Affairs (VA) hospital and then were transferred on or after January 1,
1997, and before July 31, 1998, to a non-VA hospital because the
program in which the residents were training would lose its
accreditation by the ACGME if the residents continued to train at the
VA hospital. In this situation, the non-VA hospital may receive a
temporary adjustment to its FTE cap to reflect those residents who were
transferred to the non-VA hospital for the duration that those
transferred residents were training at the non-VA hospital. In the
August 1, 2000 interim final rule with comment period, we specified
that, in order to receive this adjustment, the non-VA hospital must
submit a request to its fiscal intermediary for a temporary adjustment
to its FTE cap, document that the hospital is eligible for this
temporary adjustment by identifying the residents who have come from
the VA hospital, and specify the length of time the adjustment is
needed.
We noted that section 407(d) of Public Law 106-113 only refers to
programs that would lose their accreditation by the ACGME. This
provision does not apply to accreditation by the American Osteopathy
Association (AOA), the American Podiatry Association (APA), or the
American Dental Association (ADA).
Under section 407(d)(3) of Public Law 106-113, this policy is
effective as if included in the enactment of Public Law 105-33, that
is, for direct GME, with cost reporting periods beginning on or after
October 1, 1997, and for IME, discharges occurring on or after October
1, 1997. If a hospital is owed payments as a result of this provision,
payments must be made immediately.
We added Secs. 412.105(f)(1)(xii) and 413.86(g)(10) to incorporate
the provisions of section 407(d) of Public Law 106-113.
We did not receive any comments on this provision and are adopting
it as final.
e. Initial Residency Period for Child Neurology Residency Programs
(Section 312 of Public Law 106-113 and 42 CFR 413.86(g)(1))
Generally, section 1886(h)(5)(F) of the Act defines the term
``initial residency period'' to mean the ``period of board
eligibility.'' The period of board eligibility is defined in section
1886(h)(5)(G) of the Act as the period recognized by ACGME as specified
in the Graduate Medical Education Directory which is published by the
American Medical Association. The initial residency period limitation
was designed to limit full Medicare payment for direct GME to the time
required to train in a single specialty. Therefore, the initial
residency period is determined based on the minimum time required for a
resident to become board eligible in a specialty and the published
periods included in the Graduate Medical Education Directory. During
the initial residency period, the residents are weighted at 1.0 FTE for
purposes of Medicare payment. Residents seeking additional specialty or
subspecialty training are weighted at 0.5 FTE.
In order to become board eligible in child neurology, residents
must complete training in more than one specialty. Thus, for example,
before the effective date of section 312 of Public Law 106-113, if a
resident enrolled in a child neurology residency program by first
completing 2 years of training in pediatrics (which is associated with
a 3-year initial residency period), followed by 3 years of training in
child neurology, the resident would be limited by the initial residency
period of pediatrics. Section 312 of Public Law 106-113 amended section
1886(h)(5) of the Act by adding at the end a clause (v) which states
that ``in the case of a resident enrolled in a child neurology
residency training program, the period of board eligibility and the
initial residency period shall be the period of board eligibility for
pediatrics plus 2 years.'' (The initial residency period for pediatrics
is currently 3 years). The policy under section 312(b) of Public Law
106-113 applies to future child neurology residents and to child
neurology residents who have already begun their training (for whom an
initial residency period was already established). However, it does not
apply to residents who have completed their child neurology training
before July 1, 2000.
In the August 1, 2000 interim final rule with comment period, we
revised Sec. 413.86(g)(1) to reflect that, effective on or after July
1, 2000, for residency programs that began before, on, or after
[[Page 39909]]
November 29, 1999, the period of board eligibility and the initial
residency period for child neurology is now the period of board
eligibility for pediatrics plus 2 years. We noted that the initial
residency period is the same for all child neurology residents,
regardless of whether or not the resident completes the first year of
training in pediatrics or neurology.
We did not receive any comments on this provision and are adopting
it as final.
f. Technical Amendment
In the August 1, 2000 interim final rule with comment period, we
indicated that it had come to our attention that the first sentence of
the then existing Sec. 413.86(g)(1) contains a technical error. The
first sentence of this paragraph reads ``For purposes of this section,
an initial residency period is the number of years necessary to satisfy
the minimum requirements for certification in a specialty or
subspecialty, plus one year.'' This section of the regulation was
revised as a result of section 13563(b) of Public Law 103-66, and was
effective only until June 30, 1995. Generally, effective July 1, 1995,
an initial residency period is defined as the minimum number of years
required for board eligibility. Therefore, we revised the first
sentence of paragraph (g)(1) of Sec. 413.86 accordingly. The remainder
of paragraph (g)(1) of Sec. 413.86 was unchanged.
We did not receive any comments on this provision and are adopting
it as final.
I. Additional Payment to Hospitals that Operate Approved Nursing and
Allied Health Education Programs
Under sections 1861(v) and 1886(a) of the Act, hospitals that
operate approved nursing or allied health education programs may be
eligible for the reimbursement of their reasonable costs of operating
such programs. Section 1886(h) of the Act establishes the methodology
for determining payments to hospitals for the direct costs of GME
programs. Section 1886(h) of the Act, as implemented in regulations at
42 CFR 413.86, specifies that Medicare payments for direct costs of GME
are based on a prospectively determined per resident amount (PRA). The
PRA is multiplied by the number of full-time equivalent residents
working in all areas of the hospital complex (and nonhospital sites,
where applicable), and the product is then multiplied by the hospital's
Medicare share of total inpatient days to determine Medicare's direct
GME payment.
Section 1886(h)(3)(D) of the Act, as added by section 4624 of
Public Law 105-33, provides a 5-year phase-in of payments to teaching
hospitals for direct costs of GME associated with services to
Medicare+Choice (managed care) enrollees for portions of cost reporting
periods occurring on or after January 1, 1998. The amount of payment
for direct GME is calculated by (1) multiplying the aggregate approved
amount (that is, the product of the PRA and the number of FTE residents
working in all areas of the hospital (and nonhospital sites, if
applicable)), by the ratio of the number of inpatient bed days that are
attributable to Medicare+Choice enrollees to total inpatient bed days,
and (2) multiplying the result by an applicable percentage.
The applicable percentages are 20 percent for portions of cost
reporting periods occurring in calendar year 1998, 40 percent in
calendar year 1999, 60 percent in calendar year 2000, 80 percent in
calendar year 2001, and 100 percent in calendar year 2002 and
subsequent years. (Section 1886(d)(11) of the Act, as added by section
4622 of Public Law 105-33, provides a 5-year phase-in of payments to
teaching hospitals for IME associated with services to Medicare+Choice
enrollees for portions of cost reporting periods occurring on or after
January 1, 1998, as well. However, the Medicare+Choice IME payments are
irrelevant for the purposes of this section of the interim final rule
with comment period, because although section 541 of Public Law 106-113
affects the payments for Medicare+Choice direct GME, it in no way
affects the payments for Medicare+Choice IME.)
1. Provisions of the August 1, 2000 Interim Final Rule with Comment
Period (Section 541 of Public Law 106-113 and 42 CFR 413.86(d) and
413.87)
Section 541 of Public Law 106-113 further amended section 1886 of
the Act by adding subsection (l) and amending section 1886(h)(3)(D) to
provide for additional payments to hospitals for nursing and allied
health education programs associated with services to Medicare+Choice
enrollees. Hospitals that operate approved nursing or allied health
education programs, as defined under the regulations at 42 CFR 413.85,
and receive Medicare reasonable cost reimbursement for these programs,
would receive additional payments. This provision is effective for
portions of cost reporting periods occurring in a calendar year,
beginning with calendar year 2000.
Section 1886(l) of the Act, as added by section 541 of Public Law
106-113, specifies the methodology to be used to calculate these
additional payments and places a limitation, that is, $60 million, on
the total amount that is projected to be expended in any calendar year.
We refer to the total amount of $60 million or less as the payment
``pool.'' We emphasize that we use the term ``pool'' solely for ease of
reference; the term reflects an estimated dollar figure, a number that
is plugged into a formula to calculate the amount of additional
payments. The term ``pool'' does not refer to a discrete fund of money
that is set aside in order to make the additional payments (thus, for
example, if the estimated ``pool'' is $50 million, we use the number
$50 million to calculate the amount of additional payments, but this
does not mean that we set aside $50 million in a separate fund from
which we make the additional payments). The total amount of additional
payments is based on the ratio of estimated total direct GME payments
for Medicare+Choice enrollees to estimated total Medicare direct GME
payments, multiplied by the total Medicare nursing and allied health
education payments. Under section 541 of Public Law 106-113, a hospital
would receive its share of these additional payments in proportion to
the amount of Medicare nursing and allied health education payments
received in the cost reporting period that ended in the fiscal year
that is 2 years prior to the current calendar year, to the total amount
of nursing and allied health payments made to all hospitals in that
cost reporting period. Section 541(b) of Public Law 106-113 amended
section 1886(h)(3) of the Act to provide that direct GME payments for
Medicare+Choice utilization will be reduced to account for the
additional payments that are made for nursing and allied health
education programs under the provisions of section 1886(l) of the Act.
In the August 1, 2000 interim final rule with comment period, we
implemented section 541 by establishing regulations at 42 CFR 413.87 to
incorporate the provisions of section 1886(l) of the Act. We specified
the rules for a hospital's eligibility to receive the additional
payment under section 1886(l), the requirements for determining the
additional payment to each eligible hospital, and the methodologies for
calculating each additional payment and for calculating the payment
``pool.'' The preamble language regarding Sec. 413.87 can be found in
the August 1, 2000 interim final rule with comment period (65 FR 47036
through 47039).
We also made a conforming change to Secs. 413.86(d)(4) through
(d)(6) to account
[[Page 39910]]
for the revised methodology in determining a hospital's Medicare+Choice
direct GME payments.
2. Provisions of the June 13, 2001 Interim Final Rule with Comment
Period
a. Additional Payment to Hospitals That Operate Approved Nursing and
Allied Health Programs (Section 512 of Public Law 106-554 and 42 CFR
413.87)
Public Law 106-554 further amended section 1886(l)(2)(C) of the
Act. Specifically, section 512 of Public Law 106-554 changed the
formula for determining the additional amounts to be paid to hospitals
for Medicare+Choice nursing and allied health costs. Under Public Law
106-113, as described above, the additional payment amount was
determined based on the proportion of each individual hospital's
nursing and allied health education payments to total nursing and
allied health education payments made across all hospitals. This
formula does not account for a hospital's specific Medicare+Choice
utilization. Section 512 of Public Law 106-554 revised this payment
formula to specifically account for each hospital's Medicare+Choice
utilization. Accordingly, we made conforming changes at Sec. 413.87 to
reflect this change. The changes are effective for portions of cost
reporting periods occurring on or after January 1, 2001. We refer the
reader to the preamble of the June 13 interim final rule with comment
period for a detailed description of the revised methodology for
calculating the additional payments (66 FR 32178).
We revised Sec. 413.87 to incorporate the provisions of section 512
of Public Law 106-554.
b. Technical Amendment
In the June 13, 2001 interim final rule with comment period, we
indicated that it had come to our attention that the regulations at
Sec. 413.86(d)(4) and Sec. 413.87(d) contained errors. The regulations
at Sec. 413.86(d)(4) had read, ``Effective for cost reporting periods
beginning on or after January 1, 2000, the product derived from step
three is reduced in accordance with the provisions of Sec. 413.87(f).''
Consistent with the statutory effective date and to clarify the intent
of the reference to Sec. 413.87(f), we revised Sec. 413.86(d)(4) to
state that, ``Effective for portions of cost reporting periods
occurring on or after January 1, 2000, the product derived from step
three is reduced by a percentage equal to the ratio of the
Medicare+Choice nursing and allied health payment ``pool'' for the
current calendar year as described at Sec. 413.87(f), to the projected
total Medicare+Choice direct GME payments made to all hospitals for the
current calendar year.'' We also made a conforming change to
Sec. 413.87(d), which had read, ``Subject to the provisions of
paragraph (f) of this section * * *.'' Instead, we revised this
language to state, ``Subject to the provisions of Sec. 413.86(d)(4) * *
*.''
J. Payment for Bad Debts (Section 541 of Public Law 106-554 and 42 CFR
413.80)
Section 4451 of Public Law 105-33 required that allowable bad debt
reimbursement for hospitals be reduced by 25 percent for cost reporting
periods beginning during FY 1998, by 40 percent for cost reporting
periods beginning during FY 1999, and by 45 percent for cost reporting
periods beginning during a subsequent fiscal year.
In the June 13, 2001 interim final rule with comment period (66 FR
32183), we implemented section 541 of Public Law 106-554. Section 541
amended section 1861(v)(1)(T) of the Act, thereby modifying the
reduction in payment for Medicare beneficiary bad debt for hospitals
made by section 4451 of Public Law 105-33. Specifically, this provision
reduced the amount of bad debts otherwise treated as allowable
reductions in revenue, attributable to the deductibles and coinsurance
amounts, by 30 percent for cost reporting periods beginning during FY
2001 and later. Therefore, for cost reporting periods beginning during
the year 2001 and later, hospital bad debt amounts otherwise allowable
will be reimbursed at 70 percent of the total allowable amount. In the
June 13 interim final rule with comment period, we revised Sec. 413.80
to implement this change.
We did not receive any comments on this provision and, therefore,
are adopting the proposed revision to Sec. 413.80 as final.
V. Changes to the Prospective Payment System for Capital-Related
Costs
A. End of the Transition Period
Federal fiscal year (FY) 2001 is the last year of the 10-year
transition period established to phase in the prospective payment
system for hospital capital-related costs. For the readers' benefit, we
are providing a summary of the statutory basis for the system, the
development and evolution of the system, the methodology used to
determine capital-related payments to hospitals, and the policy for
providing exceptions payments during the transition period.
Section 1886(g) of the Act requires the Secretary to pay for the
capital-related costs of inpatient hospital services ``in accordance
with a prospective payment system established by the Secretary.'' Under
the statute, the Secretary has broad authority in establishing and
implementing the capital prospective payment system. We initially
implemented the capital prospective payment system in 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).
The 10-year transition period established to phase-in the
prospective payment system for capital-related costs is effective for
cost reporting periods beginning on or after October 1, 1991 (FY 1992)
and before October 1, 2001 (FY 2002). Beginning in FY 2001, the last
year of the 10-year transition period for the prospective payment
system for hospital capital-related costs, capital prospective payment
system payments are based solely on the Federal rate for the vast
majority of hospitals. Since FY 2001 is the final year of the capital
transition period, we will no longer determine a hospital-specific rate
for FY 2002 in section III. of the Addendum of this final rule. For
cost reporting periods beginning on or after October 1, 2001, payment
for capital-related costs for all hospitals, except those defined as
new hospitals under Sec. 412.324(b), will be determined based solely on
the capital standard 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.
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
[[Page 39911]]
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 were
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.
Hospitals that are defined as ``new'' for the purposes of capital
payments during the transition period (see Sec. 412.300(b)) will
continue to be paid according to the applicable payment methodology
outlined in Sec. 412.324. During the transition period, new hospitals
are exempt from the prospective payment system for capital-related
costs for their first 2 years of operation and are paid 85 percent of
their reasonable capital-related costs during that period. The
hospital's first 12-month cost reporting period (or combination of cost
reporting periods covering at least 12 months), beginning at least 1
year after the hospital accepts its first patient, serves as the
hospital's base period. Those base year costs qualify as old capital
and are used to establish its hospital-specific rate used to determine
its payment methodology under the capital prospective payment system.
Effective with the third year of operation and through the remainder of
the transition period, the hospital will be paid under either the fully
prospective methodology or the hold-harmless methodology. If the fully
prospective methodology is applicable, the hospital is paid using the
appropriate transition blend of its hospital-specific rate and the
Federal rate for that fiscal year until the conclusion of the
transition period, at which time the hospital will be paid based on 100
percent of the Federal rate. If the hold-harmless methodology is
applicable, the hospital will receive hold-harmless payment for assets
in use during the base period for 8 years, which may extend beyond the
10-year transition period.
The basic methodology for determining capital prospective payments
based on the Federal rate is set forth in Sec. 412.312. For the purpose
of calculating payments for each discharge, 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)
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.
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, 1997, under amendments to the Act enacted by section 4406 of
Public Law 105-33, operating payments to hospitals in Puerto Rico are
based on a blend of 50 percent of the applicable standardized amount
specific to Puerto Rico hospitals and 50 percent of the applicable
national average standardized amount. In conjunction with this change
to the operating blend percentage, effective with discharges on or
after October 1, 1997, we compute capital payments to hospitals in
Puerto Rico based on a blend of 50 percent of the Puerto Rico rate and
50 percent of the Federal rate as specified in the regulations at
Sec. 412.374. 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-related costs.
In the August 30, 1991 final rule (56 FR 43409), we established a
capital exceptions policy, which provided for exceptions payments
during the transition period (Sec. 412.348). Section 412.348 provides
that during the transition period, a hospital may receive additional
payment under the 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 have received 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 has been subject to the
capital prospective payment transition rules. The minimum payment
percentages throughout the transition period for regular capital
exceptions payments by class of hospitals 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.
The provision for ``regular'' exceptions payments expires at the
end of the transition period, that is, for cost reporting periods
beginning after September 30, 2001. Capital prospective payment system
payments are no longer adjusted to reflect regular exceptions payments
at Sec. 412.348 after that date. Accordingly, for cost reporting
periods beginning on or after October 1, 2001, all hospitals other than
those defined as ``new'' under Sec. 412.324(b) will receive only the
per discharge payment based on the Federal rate for capital costs (plus
any applicable DSH or IME and outlier adjustments) unless a hospital
qualifies for a special exceptions payment under Sec. 412.348(g).
B. Special Exceptions Process
In the August 30, 1991 final rule (56 FR 43409), we established a
capital exceptions policy at Sec. 412.348, which provided for regular
exception payments during the transition period. In the September 1,
1994 final rule (59 FR 45385), we added the special exceptions process,
describing it 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.''
Under the special exceptions provisions at Sec. 412.348(g), an
additional payment may be made through the 10th year beyond the end of
the capital
[[Page 39912]]
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 patient percentage of at least 20.2 percent, and
hospitals with a combined Medicare and Medicaid inpatient utilization
of at least 70 percent.
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
10-year transition to the fully Federal capital prospective payment
system. Therefore, hospitals are eligible to receive special exceptions
payments for the 10 years after the cost reporting year in which they
complete their project. Generally, if a project is completed in the
hospital cost reporting period ending September 29, 2002, exceptions
payments would continue through September 29, 2012. In addition, we
believe that, for projects completed after the deadline, hospitals
would have had the opportunity to reserve their prior years' capital
prospective payment system payments for financing projects. We note
that the August 1, 2000 final rule (65 FR 47095) incorrectly stated
that special exceptions payments could extend through September 30,
2011; the date should have been September 29, 2012.
For each cost reporting period, the amount of the special
exceptions payment is determined by comparing the cumulative payments
made to the hospital under the capital payment system to the cumulative
minimum payment levels applicable to the hospital for each cost
reporting period subject to the prospective payment system. This
comparison is offset or reduced by (1) any amount by which the
hospital's cumulative payments exceed its cumulative minimum payments
under the regular exceptions process for all cost reporting periods
during which the hospital has been subject to the capital prospective
payment system; and (2) any amount by which the hospital's current year
Medicare inpatient operating and capital prospective payment system
payments (excluding 75 percent of its operating DSH payments) exceed
its Medicare inpatient operating and capital costs (or its Medicare
inpatient margin). During the capital prospective payment system
transition period, the minimum payment level under the regular
exceptions process varied by class of hospital as set forth in
Sec. 412.348(c) and described in section V.A. of this preamble. After
the transition period and for the duration of the special exceptions
provision, the minimum payment level is 70 percent as set forth in
Sec. 412.348(g)(6).
As we indicated in the July 30, 1999 final rule (64 FR 41526), we
have little information about the number of hospitals that may qualify
for special exceptions payments or the projected dollar amount of
special exception payments, because no hospitals are currently being
paid under the special exceptions process. Until FY 2002, the special
exceptions provision pays either the same as the regular exceptions
process or less for high DSH and sole community hospitals. In
accordance with Sec. 412.348(g)(7), a qualifying hospital may receive
additional payments for up to 10 years from the year in which it
completes a project that meets the project need and project size
requirements of the special exception provision in Secs. 412.348(g)(2)
through (g)(5). Because a qualifying project under the special
exceptions provision at Sec. 412.348(g) must be completed (put into use
for patient care) by the end of the hospital's last cost reporting
period beginning before the end of the transition period (September 30,
2001), a hospital may receive special exception payments for 10 years
through September 30, 2012. For example, an eligible hospital that
completes a qualifying project in October 1993 (FY 1994) will be
eligible to receive special exception payments up through FY 2003
(September 30, 2003).
In order to assist our fiscal intermediaries in determining the end
of the 10-year period in which an eligible hospital will no longer be
entitled to receive special exception payments, in the May 4, 2001
proposed rule, we proposed to add a new Sec. 412.348(g)(9) to require
that hospitals eligible for special exception payments under
Sec. 412.348(g) submit documentation to the intermediary indicating the
completion date of their project (the date the project was put in use
for patient care) that meets the project need and project size
requirements outlined in Secs. 412.348(g)(2) through (g)(5). We
proposed that, in order for an eligible hospital to receive special
exception payments, this documentation would have to be submitted in
writing to the intermediary by the later of October 1, 2001, or within
3 months of the end of the hospital's last cost reporting period
beginning before October 1, 2001, during which a qualifying project was
completed. For example, if a hospital completed a qualifying project in
March 1995, it would be required to submit documentation to the
intermediary by October 1, 2001. If a hospital with a 12-month cost
reporting period beginning on July 1 completed a qualifying project in
November 2001, it would be required to submit documentation to the
intermediary no later than September 30, 2002, which is 3 months after
the end of its 12-month cost reporting period that began on July 1,
2001.
We did not receive any comments on our proposed revision to
Sec. 412.348 to add paragraph (g)(9). Accordingly, we are adopting the
proposed revision as final without change.
C. Exceptions Minimum Payment Level
Section 412.348(h) limits the estimated aggregate amount of
exceptions payments under both the regular exceptions and special
exceptions process to no more than 10 percent of the total estimated
capital prospective payment system payments in a given fiscal year.
Consistent with the requirements for regular exceptions at
Sec. 412.348(c), in the May 4, 2001 proposed rule, we proposed that if
we estimate that special exception payments would exceed 10 percent of
total capital prospective payment system payments for a given fiscal
year, we will adjust the minimum payment level of 70 percent by one
percentage point increments until the estimated payments are within the
10-percent limit. For example, we could set the minimum payment level
at 69 percent to ensure that estimated aggregate special exceptions
payments do not exceed 10 percent of estimated total capital
prospective payment system payments. If the estimate of aggregate
special exceptions payments were still projected to exceed 10 percent
of total capital prospective payment system payments, we would continue
reducing the minimum payment level by one percentage point increments
until the requirements in Sec. 412.348(h) were satisfied. We proposed
to revise Sec. 412.348(g)(6) accordingly to reflect this policy.
We received no comments on this proposed change. Thus, we are
revising Sec. 412.348(g)(6) accordingly.
D. Exceptions Adjustment Factor
Section 412.308(c)(3) requires that the standard capital Federal
rate be reduced by an adjustment factor equal to the estimated
proportion of additional payments for both regular exceptions and
special exceptions under Sec. 412.348
[[Page 39913]]
relative to total capital prospective payment system payments. In
estimating the proportion of regular exceptions payments to total
capital prospective payment system payments during the transition
period, we used the model originally developed for determining budget
neutrality (described in Appendix B of this final rule) to determine
the exception adjustment factor, which was applied to both the Federal
and hospital-specific rates. In the May 4, 2001 proposed rule, we
described our proposed methodology for determining the special
exceptions adjustment used in establishing the Federal capital rate as
follows:
Under the special exceptions provision specified at
Sec. 412.348(g)(1), eligible hospitals include SCHs, urban hospitals
with at least 100 beds that have a disproportionate share patient
percentage of at least 20.2 percent or qualify for DSH payments under
Sec. 412.106(c)(2), and hospitals with a combined Medicare and Medicaid
inpatient utilization of at least 70 percent. An eligible hospital may
receive special exception payments if it meets (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; (2) an age
of assets test as described at Sec. 412.348(g)(3); and (3) a project
size requirement as described at Sec. 412.348(g)(5).
In order to determine the estimated proportion of special
exceptions payments to total capital payments, we attempted to identify
the universe of eligible hospitals that may potentially qualify for
special exception payments. First, we identified hospitals that met the
eligibility requirements at Sec. 412.348(g)(1). Then we determined each
hospital's average fixed asset age in the earliest available cost
report starting in FY 1992 and later. For each of those hospitals, we
calculated the average fixed asset age by dividing the accumulated
depreciation by the current year's depreciation. In accordance with
Sec. 412.348(g)(3), a hospital must have an average age of buildings
and fixed assets above the 75th percentile of all hospitals in the
first year of capital prospective payment system. In the September 1,
1994 final rule (59 FR 45385), we stated that, based on the June 1994
update of the cost report files in HCRIS, the 75th percentile for
buildings and fixed assets for FY 1992 was 16.4 years. However, we
noted that we would make a final determination of that value on the
basis of more complete cost report information at a later date. In the
August 29, 1997 final rule (62 FR 46012), based on the December 1996
update of HCRIS and the removal of outliers, we finalized the 75th
percentile for buildings and fixed assets for FY 1992 as 15.4 years.
Thus, for the proposed rule, we eliminated any hospitals from the
potential universe of hospitals that may qualify for special exception
payments if its average age of fixed assets did not exceed 15.4 years.
For the hospitals remaining in the potential universe, we proposed
to estimate the project-size by using the fixed capital acquisitions
shown on Worksheet A7 from the following HCRIS cost reports updated
through December 2000.
------------------------------------------------------------------------
Cost reports periods
PPS Year beginning in . . .
------------------------------------------------------------------------
IX....................................... FY 1992
X........................................ FY 1993
XI....................................... FY 1994
XII...................................... FY 1995
XIII..................................... FY 1996
XIV...................................... FY 1997
XV....................................... FY 1998
XVI...................................... FY 1999
------------------------------------------------------------------------
Because the project phase-in may overlap 2 cost reporting years, we
proposed to add together the fixed acquisitions from sequential pairs
of cost reports to determine project size. Under Sec. 412.348(g)(5),
the project-size must meet the following requirements: (1) $200
million; or (2) 100 percent of its operating cost during the first 12-
month cost reporting period beginning on or after October 1, 1991. We
proposed to calculate the operating costs from the earliest available
cost report starting in FY 1992 and later by subtracting inpatient
capital costs from inpatient costs (for all payers). We proposed not to
subtract the direct medical education costs as those costs are not
available on every update of the HCRIS minimum data set. If the
hospital met the project size requirement, we assumed that it also met
the project need requirements at Sec. 412.348(g)(2) and the excess
capacity test for urban hospitals at Sec. 412.348(g)(4).
Because we estimate that so few hospitals will qualify for special
exceptions, projecting costs, payments, and margins would result in
high statistical variance. Consequently, we modeled the effects of
special exceptions using historical data based on hospitals' actual
cost experiences. If we determined that a hospital may qualify for
special exceptions, we modeled special exceptions payments from the
project start date through the last available cost report (FY 1999).
For purposes of modeling, we used the cost and payment data on the cost
reports from HCRIS assuming that special exceptions would begin at the
start of the qualifying project. In other words, when modeling costs
and payment data we proposed to ignore any regular exception payments
that these hospitals may otherwise have received as if there had not
been regular exceptions during the transition period. In projecting an
eligible hospital's special exception payments, we applied the 70-
percent minimum payment level, the cumulative comparison of current
year capital prospective payment system payments and costs, and the
cumulative operating margin offset (excluding 75 percent of operating
DSH payments).
Because hospitals may receive regular exceptions payments up
through the end of their last cost reporting period beginning before
October 1, 2001, hospitals with cost reporting periods beginning on a
day other than October 1 will continue to receive regular exception
payments until the end of their FY 2002 cost reporting period.
Therefore, these hospitals will only receive special exception payments
for the remainder of Federal FY 2002. Consequently, the special
exceptions payments made in FY 2002 will be less than for subsequent
years since they are only being paid a special exception payment for a
portion of FY 2002.
Based on more recent data and HCRIS cost reports updated through
March 2001, our modeling of special exception payments produced the
following results:
[[Page 39914]]
----------------------------------------------------------------------------------------------------------------
Special
exceptions as
a fraction of
Special capital
Number of exceptions as payments to
hospitals a fraction of all hospitals
Cost report eligible for capital weighted by
special payments to portion of FY
exceptions all hospitals 2002 for which
special
exceptions are
paid
----------------------------------------------------------------------------------------------------------------
PPS IX.......................................................... .............. .............. ..............
PPS X........................................................... .............. .............. ..............
PPS XI.......................................................... 3 .............. ..............
PPS XII......................................................... 6 0.0001 0.0001
PPS XIII........................................................ 7 0.0001 0.0000
PPS XIV......................................................... 14 0.0002 0.0001
PPX XV.......................................................... 17 0.0009 0.0002
PPS XVI......................................................... 23 0.0009 0.0007
----------------------------------------------------------------------------------------------------------------
Currently, the PPS XVI cost reports in HCRIS are incomplete because
there is a 2-year lag time between the end of a hospital's cost
reporting period and the submission and processing of the cost reports
for HCRIS. In particular, we have not received all the cost reports for
hospitals whose cost reporting periods begin in July. We expect that
more hospitals may qualify for special exceptions once data from later
HCRIS updates are available. In addition, hospitals still have two more
cost reporting periods (PPS XVII and PPS XVIII) to complete their
projects in order to be eligible for special exceptions.
In the May 4, 2001 proposed rule (66 FR 22705), we estimated that
about 30 additional hospitals could qualify for special exceptions.
Based on more recent data, we still estimate that about 30 additional
hospitals could qualify for special exceptions. Thus, we project that
special exception payments as a fraction of capital payments to all
hospitals is approximately 0.0025. However, after weighting this amount
to account for the FY 2002 phase-in of special exception payments, we
project that this factor is approximately 0.0012. These projections
have not changed since the publication of the May 4, 2001 proposed rule
(66 FR 22706). We received no comments on our proposed methodology for
determining the special exceptions adjustment used in establishing the
capital Federal rate. Because special exceptions are budget neutral, we
will offset the Federal capital rate by 0.12 percent for special
exceptions for FY 2002. Therefore, the final special exceptions
adjustment factor is equal to 0.9988 (1-0.0012) to account for special
exception payments in FY 2002.
E. Provisions Relating to Capital Prospective Payments in the June 13,
2001 Interim Final Rule With Comment Period
In the June 13, 2001 interim final rule with comment period, we
implemented section 301(b) of Public Law 106-554 (66 FR 32176). Section
301(b) provides for a special rule for payment for the operating
standardized amounts for hospitals other than SCHs for FY 2001. For
discharges occurring on or after April 1, 2001, and before October 1,
2001, the update to the operating standardized amounts for hospitals
other than SCHs is equal to the market basket percentage increase plus
1.1 percentage points. This provision amends the prior statutory 1.1
percent reduction to the update to the FY 2001 operating standardized
amounts for hospitals other than SCHs as provided by section 4401(a)(1)
of Public Law 105-33 and 406 of Public Law 106-113.
Section 1886(d)(3)(B) of the Act directs the Secretary to adjust
the inpatient operating national standardized amounts to account for
the estimated proportion of operating DRG payments made to payments in
outlier cases. Accordingly, as a result of this change to the update to
the operating standardized amounts for discharges occurring on or after
April 1, 2001 and before October 1, 2001, we revised the fixed-loss
outlier threshold. The regulations at Sec. 412.312(c) establish a
unified outlier methodology for inpatient operating and inpatient
capital-related costs, which utilizes a single set of thresholds to
identify outlier cases for both inpatient operating and inpatient
capital prospective payment system payments.
Because operating DRG payments increased as a result of
implementing section 301 of Public Law 106-554, the fixed-loss outlier
threshold decreased, which resulted in an increase in estimated outlier
payments. Thus, the capital national outlier adjustment factor was
revised. Since the revision to the fixed-loss outlier threshold also
affected total capital payments, the exceptions adjustment factor was
also revised in order to maintain budget neutrality. The exceptions
adjustment factor is determined based on an estimate of the ratio of
exception payments to total capital payments. The GAF/DRG budget
neutrality factor was also revised. We discuss the impact of changes to
the rates and payments under the capital prospective payment system
that result from implementation of section 301 of Public Law 106-554 in
further detail in the Addendum of this final rule.
We did not receive any comments on the revised FY 2001 capital
Federal rate for discharges occurring on or after April 1, 2001 and
before October 1, 2001 as a result of implementing section 301(b) of
Public Law 106-554.
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) and (g))
1. Updated Caps for Existing Hospitals and Units
Section 1886(b)(3) of the Act (as amended by section 4414 of Public
Law 105-33) established caps on the target amounts for certain existing
hospitals and units excluded from the prospective payment system 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 classes of excluded hospitals: psychiatric hospitals
and units, rehabilitation hospitals and units, and long-term care
hospitals.
In addition, section 4416 of Public Law 105-33 limited payments for
[[Page 39915]]
psychiatric hospitals and units, rehabilitation hospitals and units,
and long-term care hospitals that first received payments on or after
October 1, 1997. Payment for these hospitals and units is limited to
the lesser of the hospital's operating costs per case or 110 percent of
the national median of target amounts for the same class of hospitals
for cost reporting periods ending during FY 1996, updated and adjusted
for differences in area wage levels.
A discussion of how the caps on the target amounts and the payment
limitation 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); the July 31, 1998 final rule (63 FR 41000), and the July 30,
1999 final rule (64 FR 41529). For purposes of calculating the caps for
existing facilities, the statute required the Secretary to estimate the
national 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 without adjusting for
differences in area wage levels. Under section 1886(b)(3)(H)(iii) of
the Act, the resulting amounts are updated by the market basket
percentage to the applicable fiscal year.
Section 121 of Public Law 106-113 amended section 1886(b)(3)(H) of
the Act to also provide for an appropriate wage adjustment to the caps
on the target amounts for existing psychiatric hospitals and units,
rehabilitation hospitals and units, and long-term care hospitals,
effective for cost reporting periods beginning on or after October 1,
1999, through September 30, 2002. On August 1, 2000, we published an
interim final rule with comment period that implemented this provision
for cost reporting periods beginning on or after October 1, 1999 and
before October 1, 2000 (65 FR 47026) and a final rule that implemented
this provision for cost reporting periods beginning on or after October
1, 2000 (65 FR 47054). This final rule addresses the wage adjustment to
the caps and payment limitations for cost reporting periods beginning
on or after October 1, 2001 as proposed in the May 4, 2001 proposed
rule.
For purposes of calculating the caps, section 1886(b)(3)(H)(ii) of
the Act requires the Secretary to first ``estimate the 75th percentile
of the target amounts for such hospitals within such class for cost
reporting periods ending during fiscal year 1996.'' Furthermore,
section 1886(b)(3)(H)(iii), as added by Public Law 106-113, requires
the Secretary to also provide for existing hospitals ``an appropriate
adjustment to the labor-related portion of the amount determined under
such subparagraph to take into account the differences between average
wage-related costs in the area of the hospital and the national average
of such costs within the same class of hospital.''
Consistent with the broad authority conferred on the Secretary by
section 1886(b)(3)(H)(iii) of the Act to determine the appropriate wage
adjustment, we account for differences in wage-related costs by
adjusting the caps to account for the following:
First, as stated in the May 4 proposed rule, we adjust each
hospital's target amount to account for area differences in wage-
related costs. For each class of hospitals (psychiatric,
rehabilitation, and long-term care), we determine the labor-related
portion of each hospital's FY 1996 target amount by multiplying its
target amount by the actuarial estimate of the labor-related portion of
costs (or 0.71553). Similarly, we determine the nonlabor-related
portion of each hospital's FY 1996 target amount by multiplying its
target amount by the actuarial estimate of the nonlabor-related portion
of costs (or 0.28447).
Next, as we stated in the May 4 proposed rule, we account for wage
differences among hospitals within each class by dividing the labor-
related portion of each hospital's target amount by the hospital's wage
index under the hospital inpatient prospective payment system. Within
each class, each hospital's wage-neutralized target amount was
calculated by adding the wage-neutralized labor-related portion of its
target amount and the nonlabor-related portion of its target amount.
Then, the wage-neutralized target amounts for hospitals within each
class were arrayed in order to determine the national 75th percentile
caps on the target amounts for each class.
Taking into account the national 75th percentile of the target
amounts for cost reporting periods ending during FY 1996 (wage-
neutralized using the FY 2000 acute care wage index), the wage
adjustment provided for under Public Law 106-113, and the applicable
update factor based on the market basket percentage increase for FY
2001, in the August 1, 2000 final rule (65 FR 47096), we established
the FY 2001 caps on the target amounts as follows:
------------------------------------------------------------------------
FY 2001 FY 2001
labor- nonlabor-
Class of excluded hospital or unit related related
share share
------------------------------------------------------------------------
Psychiatric................................... $8,131 $3,233
Rehabilitation................................ 15,164 6,029
Long Term Care................................ 29,284 11,642
------------------------------------------------------------------------
In reviewing our methodology for wage neutralizing the hospital
specific target amounts, it appears that we incorrectly used the FY
2000 hospital inpatient prospective payment system wage index published
in Tables 4A and 4B of the July 30, 1999 final rule (64 FR 41585
through 41593), which is based on wage data after taking into account
geographic reclassification under section 1886(d)(8) of the Act. As
stated in the May 4 proposed rule, we are revising the methodology of
wage neutralizing the hospital-specific target amounts using pre-
reclassified wage data. We recalculate the limit for new excluded
hospitals and units, as well as calculate the cap for existing excluded
hospitals and units, using the pre-reclassification wage index. The
pre-reclassification wage index is the same wage index used under the
prospective payment system for skilled nursing facilities (SNFs) and
was included in Table 7 of the July 30, 1999 SNF final rule (64 FR
41690). (We note that both SNFs and ambulatory surgical centers use the
prospective payment system inpatient wage index without regard to the
prospective payment system reclassification as a proxy for variations
in local costs.)
As we stated in the August 1, 2000 final rule, long-term care
hospitals, rehabilitation hospitals and units, and psychiatric
hospitals and units that are exempt from the prospective payment system
are not subject to the prospective payment system hospital
reclassification system under section 1886(d)(10)(A) of the Act. This
section establishes the MGCRB for the purpose of evaluating
applications from short-term, acute care providers. There is no
equivalent statutory mandate for HCFA to develop an alternative board
for long-term care hospitals, psychiatric hospitals and units, and
rehabilitation hospitals and units. In addition, while it would be
feasible to allow units physically located in prospective payment
system hospitals that have been reclassified by the MGCRB to use the
wage index for the area to which that hospital has been reclassified,
at the present time there is no process in place to make
reclassification determinations for freestanding excluded providers.
There are approximately 1,000 freestanding excluded providers.
Therefore, in the interest of equity, we believe that, in determining a
hospital's wage-adjusted
[[Page 39916]]
cap on its target amount, it is appropriate for excluded hospitals and
units to use the wage index associated with the area in which they are
physically located (MSA or rural area) and the prospective payment
system reclassification under section 1886(d)(10) of the Act is not
applicable. This policy is also consistent with the policy for SNFs and
ambulatory surgical centers that use the acute care, inpatient hospital
prospective payment system wage index and that does not allow for
reclassifications since there is no analogous determinations process to
the MGCRB. The MGCRB only has authority over the prospective payment
system for acute care hospitals.
Therefore, based on the broad authority conferred on the Secretary
by section 1886(b)(3)(H)(iii) of the Act to determine the appropriate
wage adjustment to the caps, we have determined the labor-related and
nonlabor-related portions of the caps on the target amounts for FY 2002
using the methodology outlined above.
------------------------------------------------------------------------
FY 2001 FY 2001
labor- nonlabor-
Class of excluded hospital or unit related related
share share
------------------------------------------------------------------------
Psychiatric................................... $8,429 $3,351
Rehabilitation................................ $15,736 $6,256
Long-Term Care................................ $31,490 $12,519
------------------------------------------------------------------------
These labor-related and nonlabor-related portions of the caps on
the target amounts for FY 2002 are based on the current estimate of the
market basket increase for excluded hospitals and units for FY 2002 of
3.3 percent and reflect the change in applying the pre-reclassified
hospital inpatient prospective payment system wage index as discussed
above. Furthermore, in accordance with section 307(a) of Public Law
106-554, which amended section 1886(b)(3) of the Act, the labor-related
and nonlabor-related portions of the cap for long-term care hospitals
for FY 2002 are increased by 2 percent. A further discussion of this
provision as it appeared in the June 13, 2001 interim final rule with
comment period (66 FR 32181) that will implement provisions of Public
Law 106-554 for FY 2001 and for periods in FY 2001 from April 1, 2001
through September 30, 2001, appears in section VI.A.4. of this
preamble.
Finally, to determine payments described in Sec. 413.40(c), the cap
on the hospital's target amount per discharge is determined by adding
the hospital's nonlabor-related portion of the national 75th percentile
cap to its wage-adjusted, labor-related portion of the national 75th
percentile cap. A hospital's wage-adjusted, labor-related portion of
the target amount is calculated by multiplying the labor-related
portion of the national 75th percentile cap for the hospital's class by
the hospital's applicable wage index. For FY 2002, a hospital's
applicable wage index is the pre-reclassified wage index under the
hospital inpatient prospective payment system (see Sec. 412.63). The
wage index values are computed based on the same data used to compute
the FY 2002 wage index values for the hospital inpatient prospective
payment system without taking into account changes in geographic
reclassification under the following: Section 1886(d)(8)(B) of the Act
for certain rural hospitals; section 401 of Public Law 106-113;
reclassifications based on MGCRB decisions; or the Secretary's
decisions under sections 1886(d)(8) through (d)(10) of the Act. For
cost reporting periods beginning on or after October 1, 2001 and before
October 1, 2002, the pre-reclassified wage index is in Tables 4G and 4H
of this final rule. A hospital's applicable wage index corresponds to
the area in which the hospital or unit is physically located (MSA or
rural area).
2. New Excluded Hospitals and Units
a. Updated Caps (Sec. 413.40(f))
Section 1886(b)(7) of the Act establishes a payment methodology for
new psychiatric hospitals and units, new rehabilitation hospitals and
units, and new long-term care hospitals. Under the statutory
methodology, for a hospital that is within a class of hospitals
specified in the statute and 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 as adjusted
for differences in area wage levels.
As discussed earlier, in reviewing our methodology for wage
neutralizing the hospital-specific target amounts, it appears we
incorrectly used the FY 2000 hospital inpatient prospective payment
system wage index published in Tables 4A and 4B of the July 30, 1999
final rule, which is based on wage data after taking into account
geographic reclassifications under section 1886(d)(8) of the Act.
Therefore, as we proposed in the May 4 proposed rule, we also are
revising the methodology of wage neutralizing the hospital-specific
target amounts using pre-reclassified wage data in our calculation of
the limit for new excluded hospitals and units.
The amounts included in the following table reflect the updated and
recalculated 110 percent of the wage neutralized national median target
amounts for each class of excluded hospitals and units for cost
reporting periods beginning during FY 2002. These figures are updated
to reflect the projected market basket increase of 3.3 percent. For a
new provider, the labor-related share of the target amount is
multiplied by the appropriate geographic area wage index, without
regard to prospective payment system reclassifications, 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.
------------------------------------------------------------------------
FY 2002 FY 2002
labor- nonlabor-
Class of excluded hospital or unit related related
share share
------------------------------------------------------------------------
Psychiatric................................... $6,815 $2,709
Rehabilitation................................ $13,465 $5,353
Long-Term Care................................ $16,701 $6,640
------------------------------------------------------------------------
b. Changes in Type of Hospital Classification (Secs. 412.23 and 412.25)
Section 1886(b)(3) of the Act (as amended by section 4414 of Public
Law 105-33) establishes caps on the target amounts for existing
psychiatric hospitals and units, rehabilitation hospitals and units,
and long-term care hospitals for cost reporting periods beginning on or
after October 1, 1997 through September 30, 2002. Section 4416 of
Public Law 105-33 amended section 1886(b)(7) of the Act to provide for
a limitation on payment for new excluded psychiatric hospitals and
units, new rehabilitation hospitals and units, and new long-term care
hospitals. Since the establishment of the caps on target amounts and
the payment limitations, there has been an increase in the number of
hospitals requesting a change from one classification type to another
(for example, from rehabilitation to long-term care). Regulations at
Sec. 412.22(d) state that ``For purposes of exclusion from the
prospective payment systems under this subpart, the status of each
currently participating hospital (excluded or not excluded) is
determined at the beginning of each cost reporting period and is
effective for the entire cost reporting period. Any changes in the
status of the hospital are made only at the start of a cost reporting
period.''
[[Page 39917]]
Even though the existing regulations directly address only a hospital
that changes from a prospective payment system hospital to an excluded
hospital, our longstanding policy has been that a change of any
classification type can be effective only at the beginning of the
provider's cost reporting period. As we stated in the May 4 proposed
rule, although the existing regulations do not directly address changes
in a classification type of excluded hospital, we believe that a change
from one classification type of excluded hospital to another type of
excluded hospital is analogous to a change from a prospective payment
system hospital to an excluded hospital. Therefore, based on our belief
that it would be consistent with our longstanding policy, we proposed
to amend our regulations to specify that a change from one excluded
hospital classification type to another type is allowed only at the
beginning of the hospital's cost reporting period.
The rationale underlying our present policy of requiring that these
types of changes should only be effective at the beginning of the cost
reporting period is the need to avoid any undue (and possibly
significant) administrative burden that could result from doing
otherwise (for example, cost allocation, cost reporting requirements,
certification issues). If we were to accept changes in an excluded
hospital's classification type from one type of classification to
another, other than at the beginning of the cost reporting period, the
hospital would need to file a terminating cost report with respect to
its original classification as well as file a separate cost report for
the remainder of the cost reporting period with respect to its new
classification. Filing these cost reports would involve gathering the
appropriate cost data, allocating the data, and apportioning the data
between the two hospital classes. Additionally, we would have to
validate the cost reports. To allow these types of changes in the
middle of a cost reporting period would result in a significant
administrative burden. We point out that this burden is applicable
equally for either a change from a prospective payment system hospital
to an excluded hospital, or a change from one excluded hospital
classification type to another classification type. Therefore, as we
proposed in the May 4 proposed rule, we are amending the regulations to
provide that the effective date of any of these classification changes
is only at the beginning of a provider's cost reporting period
(Sec. 412.23(i), for excluded hospitals, and Sec. 412.25(f), for
excluded units).
We did not receive any public comments on our proposed revisions of
Secs. 412.23(i) and 412.25(f). Therefore, we are adopting the proposed
revisions as final.
3. Effective Date of Exclusion of Long-Term Care Hospitals
Existing regulations at Sec. 412.23(e) require a newly established
long-term care hospital to operate for at least 6 months with an
average length of stay in excess of 25 days in order to qualify for
exclusion from the inpatient hospital prospective payment system as a
long-term care hospital. Other regulations at Sec. 412.22(d) allow
changes in a hospital's status from not excluded to excluded to occur
only at the start of a cost reporting period. These two regulations,
taken together, typically require a hospital to operate for at least 6
months under the prospective payment system before becoming eligible
for payment at the more favorable rate under section 1886(b)(3) of the
Act.
These regulations were challenged in litigation by a chain
organization that operates a large number of long-term care hospitals
(Transitional Hospitals Corporation of Louisiana, Inc. v. Shalala, 222
F.3d 1019 (D.C. Cir. 2000) (THC)). Although the court of appeals in
this case found that the Secretary has ample authority to adopt current
regulatory provisions, it also concluded that the Secretary could have
considered other policy options. Consequently, it remanded the case to
the agency for the agency to consider whether it wanted to continue its
existing policy or adopt a policy of either ``self-certification'' or
``retroactive adjustment.'' Generally, under a self-certification
approach, hospitals that have not yet demonstrated the required average
length of stay would be excluded from the prospective payment system
based on a commitment to maintain such a length of stay. Under a
retroactive adjustment approach, a hospital's long-term care
classification would be made effective with the beginning of the 6-
month period in which it demonstrated the required average length of
stay. Payments for that period initially would be made under the
prospective payment system and then adjusted retroactively to amounts
payable for an excluded long-term care hospital once length of stay was
successfully established.
As directed by the court of appeals, we reviewed the issues raised
in this case in light of the court's decision, and specifically
considered the options of self-certification and retroactive
adjustment. Our proposals, and the alternatives we considered before
arriving at them, are explained in detail in the May 4, 2001 proposed
rule (66 FR 22708) and summarized below.
Although we understood that we have discretion to select other
policy options, we proposed to continue our policy of requiring
hospitals seeking long-term care hospital classification to demonstrate
the required average length of stay based on 6 months of data, instead
of permitting these hospitals to ``self-certify'' the required average
length of stay.
We noted that the statute provides the agency with broad authority
to determine the methodology by which facilities can qualify for
exclusion as long-term care hospitals (section 1886(d)(1)(B)(iv)(I) of
the Act specifies that ``a hospital which has an average inpatient
length of stay (as determined by the Secretary) of greater than 25
days'' qualifies for exclusion as a long-term care hospital). As the
court of appeals decided, the parenthetical phrase as determined by the
Secretary ``gives the Secretary considerable leeway to determine
whether to require prospective, contemporaneous, or retrospective
evaluation and payment.'' (THC at 1026.)
Having proposed to continue our policy of not allowing a hospital
to self-certify the required average length of stay in order to be paid
as an excluded long-term care hospital, we also considered the
effective date of excluded status for a hospital that has demonstrated
the required average length of stay. We considered making long-term
care classification effective retroactively with the beginning of the
6-month period in which the hospital demonstrated the required average
length of stay. However, we believe that such retroactive application
of excluded status is inappropriate.
Therefore, we proposed to continue our policy that a hospital's
payment as a long-term care hospital would be effective with the
beginning of the hospital's cost reporting period that follows the
determination to classify the hospital as a long-term care hospital.
Comment: One commenter expressed general approval of the policies
set forth in the May 4 proposed rule, stating that hospitals seeking
long-term care status should be required to demonstrate the required
length of stay based on 6 months of data.
Response: We appreciate the support of the commenter for our
proposed policy.
Comment: Another commenter disagreed with our proposed policy and
requested that we reconsider it. This commenter stated that our
proposals were inconsistent with the purpose of
[[Page 39918]]
the prospective payment system exclusion, resulted in disparate
treatment of similarly situated providers, and produced inappropriate
reimbursement shortfalls. The commenter also argued that our reliance
on the general prospective nature of the prospective payment system was
misplaced and inconsistent with our regulations.
Response: We have examined the commenter's contentions in detail
but have concluded that they do not warrant adoption of a policy
different from the one we have proposed. First, we disagree that our
proposal is inconsistent with the purpose of the long-term care
hospital exclusion. We agree with the commenter that the purpose of the
exclusion is to ensure adequate reimbursement to hospitals that treat
long-stay patients. However, the question addressed by our proposed
policy is how to determine which providers meet the criteria for being
considered hospitals that treat such patients. We believe that our
proposed policy is the most appropriate methodology for making this
determination. We believe that our proposed policy furthers the purpose
of the exclusion by ensuring that only hospitals that can demonstrate
compliance with the statutorily required length of stay receive long-
term care hospital status. It also ensures that decisions granting such
status are implemented in accordance with the general goals of the
prospective payment system and our longstanding policies regarding the
effective dates of changes in the various components of providers'
prospective payment system payment rates.
Second, we do not agree with the commenter's contention that our
proposed policy results in disparate treatment of similarly situated
providers because we allow rehabilitation hospitals to self-certify
that they will meet certain aspects of the criteria for exclusion but
do not allow long-term care hospitals to do so. We dealt with this
issue at length in the May 4 proposed rule and explained there that the
differences in the nature of the two types of facilities, and the
differences in their statutory and regulatory definitions, justified
their varying treatment for these purposes. The commenter's assertion
that the self-certification option that is permitted as to
rehabilitation facilities and the same type of option that is not
permitted as to long-term care hospitals both relate to the types of
patient to be admitted--even if true in some general sense--is not
sufficient in our view to overcome the clear differences in the two
types of facilities that informs our different treatment of them.
Similarly, the fact that long-term care hospitals must meet a
series of regulatory conditions of participation does not make them
sufficiently similar to rehabilitation hospitals so as to make the use
of self-certification by long-term care hospitals appropriate, as the
commenter suggested. All hospitals must meet conditions of
participation to participate in the Medicare program. However, that
does not change the fact that, as pointed out in the May 4 proposed
rule, the statute itself requires that a hospital meet the length of
stay criterion to qualify as a long-term care hospital, while the
statute grants the Secretary broad authority to promulgate various
criteria for a hospital to qualify as a rehabilitation hospital. It is
the additional certainty supplied by the additional criteria for status
as a rehabilitation hospital under this authority that has led us to
allow rehabilitation hospitals to self-certify that they will comply
with the remaining criterion. Such certainty is lacking in the case of
long-term care hospitals, since the length-of-stay criterion is
extremely difficult to predict into the future at any particular point
in time.
Conditions of participation exist as a matter of Medicare survey
and certification activities to ensure that the provider meets the
requirements of participation in the program, not as definitional
criteria that establish a hospital's status for payment purposes. As a
result, they do not provide the type of additional certainty that
derives from the nature and number of rehabilitation hospital criteria
and that might warrant allowing long-term care facilities to self-
certify that they will meet the required average length of stay. The
commenter also pointed out that there are various criteria in
Sec. 412.22(e) that a facility must meet to qualify as a hospital
within a hospital. However, the existence of these criteria does not
alter the fact that a hospital must meet the statutory length-of-stay
criterion in order to qualify as a long-term care hospital, making
self-certification by such a hospital inappropriate.
The commenter suggested that, if we reject its suggestion to allow
self-certification by long-term care hospitals, we should then adopt a
policy whereby we would pay a long-term care hospital provisionally
under the prospective payment system during its initial cost reporting
period; evaluate compliance with the length-of-stay requirement at the
end of that period; and, if the requirement had been met, retroactively
adjust its reimbursement to provide for payment on a reasonable cost
basis. We do not agree with the commenter that such a scheme would
result in no significant administrative burden because the retroactive
adjustments could be made as part of the cost report review process.
Whether performed as part of this process or not, the scheme the
commenter suggested would result in just the type of burden that has
generally led to our making changes in components of the prospective
payment system rates prospective only, as noted in the May 4 proposed
rule. As also noted in the proposed rule, such prospective only changes
are consistent with our approach, validated by the courts in cases like
THC, Methodist Hospital of Sacramento, and County of Los Angeles, of
balancing absolute accuracy and finality and favoring the latter in the
context of the prospective payment system. We find nothing in the
commenter's suggestions on this point that persuades us to depart from
our intention to adopt our proposed policy.
Third, we disagree with the commenter's statement that our proposed
policy produces inappropriate reimbursement shortfalls. To the
contrary, as noted above, our policy is designed to identify those
hospitals that qualify for appropriate payment as long-term care
facilities, in accordance with principles of prospectivity that have
been approved by the courts. Although the commenter stated that
Congress did not intend for us to require that new long-term care
hospitals wait at least 6 months before being excluded from the
hospital inpatient prospective payment system, the court of appeals in
THC specifically found that the Medicare statute did not preclude just
such a policy. We also note that, while the policy described in the May
4 proposed rule is one of longstanding, Congress has never seen fit to
amend the statute to require us to implement long-term care exclusions
immediately upon a new hospital's participation in the program.
Finally, we do not agree with the commenter that our reliance on
the prospective nature of the prospective payment system in arriving at
our proposed policy is misplaced or that the policy conflicts with our
regulations. As to the former point, as noted above, we believe that
the court decisions in THC, Methodist Hospital of Sacramento, and
County of Los Angeles directly support the adoption of our proposed
policy. We do not find the commenter's analyses of these cases
persuasive. They cannot be distinguished on the basis that they apply
to hospitals paid under the hospital inpatient prospective payment
system but not to hospitals excluded
[[Page 39919]]
from the prospective payment system, as the commenter suggested. Making
the determination whether a hospital is excluded from or subject to the
hospital inpatient prospective payment is an important part of
implementing the prospective payment system payment methodology, and,
like other aspects of that implementation, should be guided by the
general principles underlying the prospective payment system. That is
especially so since the ``default'' payment mode for acute care
hospitals is payment subject to the hospital inpatient prospective
payment system, and reasonable cost payment does not result until it is
determined (again, as part of administering the prospective payment
system) that the hospital's status should change to excluded status.
Moreover, while the court of appeals in Methodist Hospital may have
stated that retroactive corrections are not necessarily inconsistent
with the hospital inpatient prospective payment system, all three cases
stand for the proposition that neither is the agency's prospective only
policy inconsistent with the statute. Indeed, that is largely the point
of the court of appeals' decision in THC--that the agency has broad
statutory authority to adopt retroactive, contemporaneous, or
prospective application of decisions granting long-term care status.
For the reasons set out in the May 4 proposed rule and in this final
rule, we have elected the latter policy. The policy at issue here is
thus quite different from the one at issue in Georgetown University
Hospital v. Bowen, 862 F.2d 323 (D.C. Cir.1988), which the commenter
also cited, because the court of appeals held that that policy was
contrary to express Congressional intent.
Nor is our proposed policy contrary to our regulations. The only
regulations that the commenter cited in support of this point are those
that implement the statutory requirement that a hospital cost report be
subject to retroactive adjustment upon review by the intermediary after
the close of the applicable cost reporting period. However, those
regulations, and the statutory provisions they implement, merely
establish a year end ``book-balancing'' process to reconcile the amount
of estimated payments made to the provider during the year with the
actual amount of reimbursement the provider is due for that year,
determined in accordance with the methods prescribed by the agency.
Among those methods is prospective only application of the prospective
payment system status decisions. These regulations then are in no way
inconsistent with our proposed policy.
4. Payment for Long-Term Care Hospital Costs: Provisions of the June
13, 2001 Interim Final Rule with Comment Period (Section 307 of Public
Law 106-554 and 42 CFR 413.40(c)(4))
a. Increase in the Limitation on the Target Amounts for Long-Term Care
Hospitals
As stated in the June 13 interim final rule with comment period (66
FR 32181), in the August 29, 1997 final rule with comment period (62 FR
46018), in accordance with section 4414 of Public Law 105-33, we
implemented section 1886(b)(3)(H) of the Act, which provides for caps
on the target amounts for existing and new 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
three classes of excluded hospitals: psychiatric hospitals and units,
rehabilitation hospitals and units, and long-term care hospitals. In
establishing the caps on the payment amounts within each class of
hospital for new hospitals, section 1886(b)(7)(C) of the Act, as
amended by section 4416 of Public Law 105-33, instructed the Secretary
to provide an appropriate adjustment to take into account area
differences in average wage-related costs. However, because the
statutory language under section 4414 of Public Law 105-33 did not
provide for the Secretary to adjust for area differences in wage-
related costs in establishing the caps on the target amounts within
each class of hospital for existing hospitals, we did not adjust for
wage-related differences for existing facilities. In the August 1, 2000
interim final rule with comment period (65 FR 47039), we implemented
section 121 of Public Law 106-113, which further amended section
1886(b)(3)(H) of the Act by directing the Secretary to provide for an
appropriate wage adjustment to the caps on the target amounts for all
psychiatric hospitals and units, rehabilitation hospitals and units and
long-term care hospitals, effective for cost reporting periods
beginning on or after October 1, 1999, through September 30, 2002. For
purposes of calculating the caps, section 1886(b)(3)(H)(ii) of the Act
requires the Secretary to first ``estimate the 75th percentile of the
target amounts for such hospitals within such class for cost reporting
periods ending during fiscal year 1996.'' Section 1886(b)(3)(H)(iii) of
the Act, as added by section 121 of Public Law 106-113, requires the
Secretary to provide for ``an appropriate adjustment to the labor-
related portion of the amount determined under such subparagraph to
take into account differences between average wage-related costs in the
area of the hospital and the national average of such costs within the
same class of hospital.''
The August 1, 2000 final rule (65 FR 47096) listed the FY 2001
labor-related share and nonlabor-related share of the national 75th
percentile wage-neutralized cap for long-term care hospitals as
follows:
Labor-related Share: $29,284
Nonlabor-related Share: $11,642
The final rule also discussed that within each class a hospital's wage-
adjusted cap on its target amount is determined by adding the
hospital's nonlabor-related portion of the national wage-neutralized
cap to its wage-adjusted labor-related portion of the national wage-
neutralized cap. A hospital's wage-adjusted labor-related portion is
calculated by multiplying the labor-related portion of the national
wage-neutralized 75th percentile cap for the hospital's class by the
hospital's applicable wage index. For FY 2001, a hospital's applicable
wage index is the wage index under the hospital inpatient prospective
payment system as shown in Tables 4A and 4B of the August 1, 2000 final
rule (65 FR 47149 through 47156) corresponding to the area in which the
hospital is physically located (MSA or rural area).
Section 307(a) of Public Law 106-554 further amended section
1886(b)(3) of the Act and provides for a 2-percent increase to the
wage-adjusted 75th percentile cap on the target amount for long-term
care hospitals effective for cost reporting periods beginning during FY
2001. This provision is only applicable to long-term care hospitals
that were subject to the cap for existing excluded providers as
specified in Sec. 413.40(c).
In accordance with section 1886(b)(3) of the Act as amended, for
cost reporting periods beginning during FY 2001, in the June 13 interim
final rule with comment period, we specified the following revised
labor-related and nonlabor-related shares of the cap on the target
amount for long-term care hospitals, which reflect the 2-percent
increase:
Revised FY 2001 National Cap for Long-Term Care Hospitals
------------------------------------------------------------------------
FY 2001 labor- related share FY 2001 nonlabor- related share
------------------------------------------------------------------------
$29,870 $11,875
------------------------------------------------------------------------
[[Page 39920]]
Note that the national 75th percentile wage-neutralized caps on the
target amount for the other excluded hospitals and units subject to the
caps under section 1886(b)(3)(H) of the Act (psychiatric and
rehabilitation) are not affected by section 307 of Public Law 106-554.
In the June 13 interim final rule with comment period, we revised the
regulations at Sec. 413.40(c)(4)(iii) to incorporate this change.
We did not receive any public comments on our proposed revision of
Sec. 413.40(c)(4)(iii) to incorporate this provision of the statute
and, therefore, are adopting it as final.
b. Increase in the Target Amounts for Long-Term Care Hospitals
As stated in the June 13, 2001 interim final rule with comment
period (66 FR 32181), in the August 29, 1997 final rule with comment
period (62 FR 46016) we implemented the amendment to section
1886(b)(3)(B) of the Act, as made by section 4411 of Public Law 105-33,
which set forth the applicable rate-of-increase percentage for cost
reporting periods beginning during FY 1999 through FY 2002. The rate-
of-increase is equal to the market basket increase percentage minus an
amount based on the percentage by which the hospital's operating costs
exceed the hospital's ceiling for the most recent available cost
reporting period. The applicable rate-of-increase percentages (update
factors) for FY 2001 are described in the August 1, 2000 final rule (65
FR 47125). For FY 2001, the market basket increase percentage was
forecast at 3.4 percent, which results in an update for long-term care
hospitals for FY 2001 of between 0.9 percent and 3.4 percent, or 0
percent, depending on the hospital's costs in relation to its rate-of-
increase limit.
In addition to the increase to the cap on the target amounts for
long-term care hospitals, section 307(a) of Public Law 106-554 also
amended section 1886(b)(3) of the Act to provide for a 25-percent
increase to the target amounts determined under section 1886(b)(3)(A)
of the Act for long-term care hospitals, for cost reporting periods
beginning in FY 2001, subject to the applicable cap on the target
amounts. Thus, this provision required a revision to the determination
of each long-term care hospital's FY 2001 target amount as specified in
Sec. 413.40(c)(4). As stated in the June 13 interim final rule with
comment period, for cost reporting periods beginning during FY 2001,
the hospital-specific target amount otherwise determined for a long-
term care hospital as specified in the regulations at
Sec. 413.40(c)(4)(ii) is multiplied by 1.25 (that is, increased by 25
percent), subject to the limitation that the revised FY 2001 target
amounts for a long-term care hospital cannot exceed its wage-adjusted
national cap as required by section 1886(b)(3) of the Act, as amended
by section 307(a) of Public law 106-554. We noted that the 25-percent
increase to the target amount under section 307(a) of Public Law 106-
554 is applicable only to long-term care hospitals, and not to other
excluded hospitals as defined in section 1886(d)(1)(B) of the Act
(psychiatric and rehabilitation hospitals and units, children's and
cancer hospitals).
In the June 13, 2001 interim final rule with comment period, we
revised the regulations at Sec. 413.40(c)(4)(iii) to incorporate this
change.
We did not receive any public comments on this revision of
Sec. 413.40(c)(4)(iii) to incorporate this provision of the statute
and, therefore, are adopting it as final.
5. Development of Prospective Payment System for Inpatient
Rehabilitation Hospitals and Units
Section 1886(j) of the Act, as added by section 4421 of Public Law
105-33, provided 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, with a fully implemented
system for cost reporting periods beginning on or after October 1,
2002. Section 1886(j) of the Act was amended by section 125 of Public
Law 106-113 to require the Secretary to use the discharge as the
payment unit under the prospective payment system for inpatient
rehabilitation services and to establish classes of patient discharges
by functional-related groups. Section 305 of Public Law 106-554 further
amended section 1886(j) of the Act to allow hospitals to elect to be
paid the full Federal prospective payment rather than the transitional
period payments specified in the Act.
Shortly, we will be issuing a final rule on the establishment of
the prospective payment system for inpatient rehabilitation facilities,
to be effective January 1, 2002.
6. Increase in the Incentive Payment for Excluded Psychiatric Hospitals
and Units: Provision of the June 13, 2001 Interim Final Rule with
Comment Period (Section 306 of Public Law 106-554 and 42 CFR
413.40(d)(2))
As we stated in the June 13 interim final rule with comment period
(66 FR 32181), for cost reporting periods beginning before October 1,
1997, a hospital that had inpatient operating costs less than, or equal
to, its ceiling was paid its costs plus the lower of 50 percent of the
difference between inpatient operating costs and the ceiling or 5
percent of the ceiling. Section 4415 of Public Law 105-33 amended
section 1886(b)(1)(A) of the Act to provide that for cost reporting
periods beginning on or after October 1, 1997, if a hospital's net
inpatient operating costs are less than or equal to, the ceiling, the
amount of the bonus payment would be the lower of 15 percent of the
difference between the inpatient operating costs and the ceiling or 2
percent of the ceiling. Section 306 of the Public Law 106-554 further
amended section 1886(b)(1)(A) of the Act, as it applied to a
psychiatric hospital or unit, to provide that effective for cost
reporting periods beginning on or after October 1, 2000, and before
October 1, 2001, if a psychiatric hospital or unit's net inpatient
operating costs are less than, or equal to, the ceiling, the amount of
the bonus payment is the lower of 15 percent of the difference between
the inpatient operating costs and the ceiling, or 3 percent of the
ceiling.
In the June 13 interim final rule with comment period, we revised
the regulations at Sec. 413.40(d)(2) to incorporate this change.
We did not receive any public comments on our revision to
Sec. 413.40(d)(2) in the interim final rule with comment period to
incorporate this provision of the statute and, therefore, are adopting
it as final.
7. 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 Public Law 104-33 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
[[Page 39921]]
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 CMS, depending on the type of
adjustment requested, then reviews the request and determines if an
adjustment payment is warranted. This determination is often not made
until more than 6 months after the date the request is filed.
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 CMS during the previous Federal fiscal year.
The table below includes the most recent data available from the
intermediaries and CMS on adjustment payments that were adjudicated
during FY 2000. By definition, these were for cost reporting periods
ending in years prior to FY 1999. The total adjustment payments awarded
to excluded hospitals and units during FY 2000 are $12,344,419. 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
Class of hospital Number over Adjustment
ceiling payment
------------------------------------------------------------------------
Psychiatric........................ 40 $19,172,613 $9,114,944
Rehabilitation..................... 8 6,128,515 2,254,393
Long-Term Care..................... 3 827,821 814,971
Children's......................... 1 160,111 160,111
------------------------------------------------------------------------
B. Critical Access Hospitals (CAHs)
Section 4201 of Public Law 105-33 amended section 1820 of the Act
to create a nationwide Medicare Rural Hospital Flexibility (MRHF)
Program to replace the 7-State Essential Access Community Hospital/
Rural Primary Care Hospital (EACH/RPCH) program. Under section
1820(c)(2) of the Act, as amended, a State could designate certain
rural hospitals as CAHs if they were located a specified distance from
other hospitals, made 24-hour emergency care available, and kept
inpatients for a limited period of time. Additionally, CAH staffing
requirements differed from those of other hospitals under Medicare and
CAHs received payment for inpatient and outpatient services on the
basis of reasonable cost. A comprehensive discussion of CAHs within the
context of the MRHF Program may be found in the August 29, 1997 Federal
Register (62 FR 45970 and 46008-46010).
1. Permitting Certain Facilities to be Designated as CAHs (Section
401(b) of Public Law 106-113 and 42 CFR 485.610)
As discussed in the August 1, 2000 interim final rule with comment
period, one of the threshold criteria for designation as a CAH under
section 1820(c)(2)(B)(i) of the Act is that the hospital must be rural
as defined in section 1886(d)(2)(D)(ii) of the Act. Section IV.A. of
the interim final rule with comment period discussed the option of
urban to rural classification for a ``subsection (d)'' hospital
authorized by section 401(a) of Public Law 106-113 under an amendment
to section 1886(d)(8) of the Act. Section 401(b)(2) of Public Law 106-
113 amended section 1820(c)(2)(B) of the Act to authorize a State to
designate a hospital in an urban area as a CAH if, under one of the
criteria set forth in section 1886(d)(8)(E) of the Act, it would be
treated as being located in the rural area of the State in which the
hospital is located. Section 401(b)(2) only provides authority for a
hospital to meet the rural requirement. We note that the hospital would
have to otherwise meet the statutory and regulatory requirements
governing CAH designation.
The first criteria in section 401(a) specified that a hospital will
be treated as located in a rural area if the hospital is located in a
rural census tract of an MSA, as determined under the most recent
Goldsmith Modification, originally published in the Federal Register on
February 27, 1992. In Appendix B of the August 1, 2000 interim final
rule with comment period, we published a listing of existing hospitals
that may qualify as CAHs because they are located in Goldsmith areas.
In the August 1, 2000 interim final rule, we specified that the
application procedures and effective dates for an urban hospital
seeking to reclassify as rural in order to apply for CAH status under
section 1820(c)(2)(B)(i) of the Act were set forth in new Sec. 412.103
that implements section 401(a), and discussed in section IV.C. of that
interim final rule with comment period (65 FR 47041). In the August 1
interim final rule with comment period, we revised the regulations on
location for CAHs at Sec. 485.610(b) to reflect this amendment.
We did not receive any comments on the revised section of the
regulations in the interim final rule with comment period and have not
made any further changes to it.
2. Exclusion of CAHs From Payment Window Requirements
Section 1886 of the Act specifies the requirements governing
payment to full-service hospitals for the operating costs of inpatient
hospital services under both the inpatient hospital prospective payment
system and the limits on the target amounts for hospitals excluded from
the prospective payment system. ``Operating costs of inpatient hospital
services'' are defined in section 1886(a)(3) of the Act, which provides
in part that costs of certain services provided to a beneficiary during
the 3 days (or in the case of an excluded hospital or unit, during the
1 day) immediately preceding the patient's admission are to be included
in the payments for costs under the inpatient hospital prospective
payment system, or costs subject to the target amount for excluded
hospitals and units. This part of the definition is sometimes referred
to as the ``payment window'' requirement. Regulations implementing the
payment window requirement are found at Sec. 412.2(c)(5) for hospitals
subject to the prospective payment system, and Sec. 413.40(c)(2) for
hospitals excluded from the prospective payment system.
As we stated in the May 4, 2001 proposed rule, payment to CAHs for
inpatient services is not made under the
[[Page 39922]]
inpatient hospital prospective payment system mandated by section 1886
of the Act, nor are CAHs considered to be hospitals excluded from the
inpatient hospital prospective payment system. Instead, payment is made
on a reasonable cost basis, as mandated by section 1814(l) of the Act.
Neither section 1814(l) nor section 1861(v) of the Act (which defines
``reasonable cost'') requires application of the payment window to
services furnished on an outpatient basis immediately before admission
to a CAH. Therefore, we stated in the May 4 proposed rule that we have
determined that the payment window provision does not apply to CAHs. To
clarify this point and avoid possible misapplication of the payment
window, we proposed to amend Sec. 413.70(a)(l) to provide that the
requirements of Secs. 412.2(c)(5) and 413.40(c)(2) do not apply to
CAHs.
Comment: Several commenters expressed support for the proposal to
explicitly exclude CAHs from the payment window requirements. None of
the commenters opposed the proposal or suggested changes to it.
Response: We appreciate the commenters' support and are adopting
the proposed regulation amendments as final.
3. Availability of CRNA Pass-Through for CAHs
Generally, anesthesia services furnished to a hospital patient by a
certified registered nurse anesthetist (CRNA) must be billed to the
Part B carrier and payment is made under the applicable fee schedule
provisions of Sec. 414.60. However, certain rural hospitals that
furnish no more than 500 surgical procedures requiring anesthesia per
year and meet other specified requirements are exempted from the fee
schedule. These hospitals are paid on a reasonable cost basis for their
costs of anesthesia services furnished by qualified nonphysician
anesthetists. The exemption is provided in accordance with section
9320(k) of the Omnibus Budget Reconciliation Act of 1986 (Public Law
99-509) (as added by section 608(c)(2) of the Family Support Act of
1988 (Public Law 100-185), as amended by section 6132 of the Omnibus
Budget Reconciliation Act of 1989 (Public Law 101-239)). We have
codified this exemption at Sec. 412.113(c).
We pointed out in the May 4 proposed rule that, although
Sec. 412.113(c) does not specifically extend eligibility for the pass-
through payment for CRNAs to CAHs, some CAHs have pointed out that they
are similar to the rural hospitals that are eligible for this payment,
in that they also furnish low volumes of surgical procedures requiring
anesthesia and could face the same problem of potentially inadequate
payment for CRNA services if they are not allowed to qualify for the
pass-through payment. We share this concern.
We recognize that the legislation cited above, which provides the
legal basis for the pass-through payments, refers only to
``hospitals,'' not to CAHs. Moreover, section 1861(e) of the Act states
that ``the term ``hospital'' does not include, unless the context
otherwise requires, a critical access hospital * * *.'' It is clear
from section 1861(e) of the Act that CAHs are not to be considered
hospitals under the Medicare law for most purposes. However, the
reference to ``context'' in the provision indicates that CAHs may be
classified as hospitals where, in specific contexts, it would be
consistent with the purpose of the legislation to do so.
We stated that we believe this is the case with the statutory
provisions authorizing pass-through payments for CRNA costs. The
purpose of the pass-through legislation is to provide small rural
hospitals with low surgical volumes with relief from the difficulties
they might otherwise have in furnishing CRNA services for their
patients. CAHs are by definition limited-service facilities located in
rural areas and, as such, they serve a population much like those
served by hospitals eligible for the pass-through payments. In some
cases, an institution that now participates as a CAH may even have been
eligible for the pass-through payments when it participated as a
hospital. Such an institution would clearly be disadvantaged if it were
to lose this status. Thus, in accordance with section 1861(e) of the
Act and in light of the context of the pass-through legislation cited
above, we consider CAHs to be ``hospitals'' for purposes of extending
eligibility for the CRNA pass-through payments to them.
Therefore, in the May 4 proposed rule, we proposed to add a new
Sec. 413.70(a)(3) and revise Secs. 413.70(a)(2), (b)(1), and (b)(6) to
permit CAHs that meet the criteria for the pass-through payments in
Sec. 412.113(c) to qualify for pass-through payments for the costs of
anesthesia services for both inpatient and outpatient surgeries, on the
same basis as full service rural hospitals. As an unrelated technical
correction, we proposed to revise Sec. 413.70(b)(2)(i)(C) to delete the
incorrect reference to Sec. 413.130(j)(2) and replace it with a
reference to reduction in capital costs under Sec. 413.130(j). We also
proposed to revise Sec. 412.113(c) by changing the term ``hospital'' to
``hospital or CAH''.
Comment: Several commenters favored extension of the CRNA pass-
through to CAHs. However, some commenters suggested that the pass-
through be made available to all CAHs, even if they furnish 500 or more
surgical procedures requiring anesthesia service in the prior year.
Response: Section 412.113(c), which is based on the provisions of
the Medicare law, is specific with respect to the volume of surgeries
that may be performed by facilities qualifying for the CRNA pass-
through. The volume of surgeries is a criterion for a hospital to
qualify for CRNA pass-through. As we are treating CAHs as hospitals for
purposes of the CRNA pass-through, a CAH would have to meet the same
qualifying criteria as would a hospital. Accordingly, we are not
adopting the commenters' suggestion that the 500 procedure criterion be
revised for CAHs.
Comment: One commenter stated that anesthesia services in many
rural facilities are furnished by anesthesiologists rather than CRNAs,
and suggested that pass-through also be made available for the costs of
anesthesia services provided by anesthesiologists.
Response: The Medicare law is specific to CRNAs and does not offer
similar treatment for costs of services of anesthesiologists.
Therefore, we are not adopting this suggestion.
4. Payment to CAHs for Emergency Room On-Call Physicians
(Sec. 413.70(b)(4))
Under section 1834(g) of the Act, Medicare payment to a CAH for
facility services to Medicare outpatients is the reasonable costs of
the CAH in providing such services. The term ``reasonable cost'' is
defined in section 1861(v) of the Act and in regulations at 42 CFR Part
413, including, with specific reference to CAHs, Sec. 413.70.
Consistent with the general policies stated in section 2109 of the
Medicare Provider Reimbursement Manual (PRM), Part I (HCFA Publication
15-1), the reasonable cost of CAH services to outpatients may include
reasonable costs of compensating physicians who are on standby status
in the emergency room (that is, physicians who are present and ready to
treat patients if necessary). However, under existing policy, the
reasonable cost of CAH services to outpatients may not include any
costs of compensating physicians who are not present in the facility
but are on call.
Section 204 of Public Law 106-554 further amended section 1834(g)
of the Act (as amended by section 201 of Public Law 106-554) by adding
a new
[[Page 39923]]
paragraph (5). New section 1834(g)(5) of the Act provides that, in
determining the reasonable costs of outpatient CAH services under
sections 1834(g)(1) and 1834(g)(2)(A) of the Act, the Secretary shall
recognize as allowable costs amounts (as defined by the Secretary) for
reasonable compensation and related costs for emergency room physicians
who are on call (as defined by the Secretary) but who are not present
on the premises of the CAH involved, are not otherwise furnishing
physicians' services, and are not on call at any other provider or
facility. The provisions of section 204 of Public Law 106-554 are
effective for cost reporting periods beginning on or after October 1,
2001.
As we provided in the May 4 proposed rule, to implement the
provisions of section 1834(g)(5) of the Act, we proposed to add a new
paragraph (4) to Sec. 413.70(b). The proposed Sec. 413.70(b)(4) would
permit the reasonable costs of CAH outpatient services to include the
reasonable compensation and related costs of emergency room on-call
physicians under the terms and conditions specified in the statute. As
directed in the statute, under Sec. 413.70(b)(4)(ii)(A) of the proposed
rule, we defined ``amounts for reasonable compensation and related
costs'' as those allowable costs of compensating emergency room
physicians for being on call, to the extent these costs are found to be
reasonable under the rules in Sec. 413.70(b)(2).
In addition, as specified under Sec. 413.70(b)(4)(ii)(A) of the
proposed rule, we defined an ``emergency room physician who is on
call'' as a doctor of medicine or osteopathy with training or
experience in emergency care who is immediately available by telephone
or radio contact, and who is available on site within the timeframes
specified in our existing regulations under Sec. 485.618(d). Existing
Sec. 485.618(d) specifies that the physician must be available on site
(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 item (2); or (2) within 60
minutes, on a 24-hour a day basis, if all of the following requirements
are met:
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.
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.
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.
We also believe that it is essential that physicians who are paid
to be in on-call status in fact come to the facility when summoned.
Therefore, we proposed to specify that costs of on-call emergency room
physicians are allowable only if the costs are incurred under written
contracts that require them to come to the CAH when their presence is
medically required.
Comment: One commenter noted that existing regulations at
Sec. 413.70(a)(2) prohibit application, in making reasonable cost
determinations for CAHs, of the reasonable compensation equivalent
(RCE) limits on physician services to providers. The commenter
expressed concern that more explicit reasonableness guidelines may be
needed to ensure that costs recognized for on-call services are
reasonable.
Response: We understand the commenter's concern, but note that
existing reasonable cost rules at Sec. 413.9(c)(2) authorize
intermediaries to disallow costs of services that are ``substantially
out of line'' with costs of other, similar providers in the same area.
We will continue to monitor these costs and will consider proposing
further or more specific reasonableness standards if necessary.
Comment: One commenter stated that contracts for emergency services
are typically executed between a CAH and a physician group, and, for
legal purposes, the individual physician is not distinguishable from
the group. The commenter further stated that if the regulations
prohibit the ``physician'' from otherwise furnishing services or being
on call at another facility, the proposed language of the regulation
may inadvertently prohibit any member of the physicians group from
otherwise furnishing services or being on call.
Response: We have reconsidered the proposed language of
Sec. 413.70(b)(4) in the light of this comment, but find no basis for
interpreting the proposed revised language in the way the commenter has
suggested may occur. The proposed revised language makes it clear that
it is the individual physician who is on call for the CAH that may not
be otherwise engaged in furnishing physician's services, or on call at
another provider or facility.
We are adopting proposed Sec. 413.70(b)(4) as final.
5. Treatment of Ambulance Services Furnished by Certain CAHs
(Sec. 413.70(b)(5))
Under section 1861(s)(7) of the Act, Medicare Part B covers and
pays for ambulance services, to the extent prescribed in regulations,
when the use of other methods of transportation would be
contraindicated. Various Congressional reports indicate that Congress
intended that (1) the ambulance benefit cover transportation services
only if other means of transportation are contraindicated by the
beneficiary's medical condition; and (2) only ambulance services to
local facilities be covered unless necessary services are not available
locally, in which case, transportation to the nearest facility
furnishing those services is covered. (H.R. Rept. No. 89-213, 89th
Cong., 1st Sess. at 37 (1995) and S. Rept. No. 89-404, 89th Cong., 1st
Sess., Pt. I, at 43 (1995).
The Medicare program currently pays for ambulance services on a
reasonable cost basis when furnished by a provider and on a reasonable
charge basis when furnished by a supplier. (The term ``provider''
includes all Medicare-participating institutional providers that submit
claims for Medicare ambulance services (hospitals, CAHs, SNFs, and home
health agencies).) The term ``supplier'' means an entity that is
independent of any provider. The reasonable charge methodology that is
the basis of payment for ambulance services is determined by the lowest
of the customary, prevailing, actual, or inflation indexed charge.
Section 4531(a)(1) of Public Law 105-33 amended section 1861(v)(1)
of the Act and imposed an additional per trip limitation on reasonable
cost payment to hospitals and CAHs for ambulance service. As amended,
the statute provides that, in determining the reasonable cost of
ambulance services furnished by a provider of services, the Secretary
shall not recognize the cost per trip in excess of the prior year's
reasonable cost per trip updated by an inflation factor. This trip
limit provision was first effective for services furnished during
Federal fiscal year 1998 (October 1, 1997 through September 30, 1998).
Section 205 of Public Law 106-554 amended section 1834(l) of the
Act by adding a new paragraph (8) to that section. New section
1834(l)(8) provides that the Secretary is to pay the reasonable costs
incurred in furnishing ambulance services if such services are
[[Page 39924]]
furnished by a CAH (as defined in section 1861(mm)(1) of the Act), or
by an entity owned and operated by the CAH. This provision in effect
eliminates any trip limit that CAHs had been subject to as a result of
section 1861(v)(1) of the Act, as amended by Public Law 105-33.
However, section 205 further states that in order to receive reasonable
cost reimbursement for the furnishing of ambulance services, the CAH or
entity must be the only provider or supplier of ambulance services
located within a 35-mile drive of the CAH. Section 205 is effective for
services furnished on or after December 21, 2000, the date of enactment
of Public Law 106-554.
As stated in the May 4 proposed rule, to implement the provisions
of section 1834(l)(8) of the Act, we proposed to add a new paragraph
(5) to Sec. 413.70(b) to permit a CAH, or an entity owned or operated
by a CAH, to be paid for furnishing ambulance services on a reasonable
cost basis if the CAH or entity is the only provider or supplier of
ambulance services within a 35-mile drive of the CAH. In determining
whether there is any other provider or supplier of ambulance services
within a 35-mile drive of a CAH or entity, we first identify the site
where the nearest other ambulance provider or supplier garages its
vehicles, and then determine whether that site is within 35 miles,
calculated as the shortest distance in miles measured over improved
roads. An improved road for this purpose is be defined as any road that
is maintained by a local, State, or Federal government entity, and is
available for use by the general public. Consistent with the change, in
the May 4 proposed rule concerning Sec. 412.92(c)(1) relating to SCH
determinations (as explained in section IV.A. of this preamble), we
proposed to consider improved roads to include the paved surface up to
the front entrance of the hospital and, for purposes of
Sec. 413.70(b)(5), the front entrance of the garage.
Comment: Several commenters recommended that we support a
legislative change that would eliminate the 35-mile requirement and
allow all designated CAHs owning ambulance services to be reimbursed at
cost. Another commenter requested that we support a legislative change
to address situations where the distance requirement involves
mountainous terrain or only secondary roads and that in such cases the
mileage requirement be 15 miles.
Response: As the commenters pointed out, the statute as currently
worded is clear as to applicability of the 35-mile rule in connection
with the requirements for cost reimbursement of ambulance services
furnished by CAHs. Therefore, we are not making any changes in the
final regulation based on these comments.
Comment: One commenter described a situation where both the CAH and
ambulance services are wholly owned by a city but the CAH provides
operating services to the ambulance company. The commenter asked
whether in such a case the ambulance services could be considered to be
furnished by an entity that is wholly owned and operated by the CAH.
Response: As stated in section 205 of the Public Law 106-554,
payment on a reasonable cost basis may be made for ambulance services
furnished by a CAH, or an entity owned and operated by the CAH. The
legislation does not allow us to extend similar treatment to ambulance
services that may be operated but not owned by a CAH. Accordingly, we
are not making any changes in this final rule based on this comment.
We are adopting proposed Sec. 413.70(b)(5) as final without change.
6. Qualified Practitioners for Preanesthesia and Postanesthesia
Evaluation in CAHs
Section 1820 of the Act sets forth the conditions for designating
certain hospitals as CAHs. Implementing regulations for section 1820 of
the Act are located in 42 CFR part 485, Subpart F. Included in the
conditions of participation regulations for CAHs in subpart F is the
condition for surgical services (Sec. 485.639). Existing Sec. 485.639
specifies that preanesthesia and postanesthesia services in a CAH can
only be performed by a doctor of medicine or osteopathy, including an
osteopathic practitioner recognized under section 1101(a)(7) of the
Act; a doctor of dental surgery or dental medicine; or a doctor of
podiatric medicine. This Medicare condition of participation
requirement regarding preanesthesia and postanesthesia evaluations for
CAHs differs from, and is more restrictive than, the current
requirement for acute care hospitals in general. In an acute care
hospital, the CRNA is listed among the practitioners who may perform
the preanesthesia and postanesthesia evaluations.
Our principal consideration in regulating providers is to ensure
patient safety and high quality patient outcomes. As circumstances and
health care environments change, we reassess regulations and propose
changes accordingly.
In the May 4 proposed rule, we stated that when the regulations for
the initial Rural Primary Care Hospital (RPCH) program (which later
became the CAH program) were adopted, RPCHs were limited to patient
stays of no more than 72 hours and to bed counts of no more than 6
acute care beds. We initially viewed RPCHs as very limited-service
facilities that would be unlikely to perform any surgery beyond what
might be done in a physician's office; therefore, we did not have a
condition of participation for surgery. Section 102(a)(1) of the Social
Security Amendments of 1994, Public Law 103-432, specifically
authorized surgical care in RPCHs. In June 1995, we proposed a surgical
condition of participation that incorporated the ambulatory surgery
center (ASC) standards. We expected that the types of procedures done
in a RPCH would most likely be those that could be done in ASCs. At the
time, we received no comments in response to the proposed standards and
therefore adopted them in the final RPCH conditions of participation
that were published on September 1, 1995 (60 FR 45851).
In 1997, the RPCH (now CAH) program was expanded through a
statutory change to include all States and to allow for an increase in
bed size and length of stay (August 29, 1997 final rule, 62 FR 46035).
Since that time, the program's original conditions of participation
have been revised (and more recently have been proposed to be revised)
to remove possible barriers to access to care. One example of our
latest effort is our proposed rule to eliminate the Federal requirement
for physician supervision of CRNAs in CAHs as well as in acute care
hospitals and ASCs that was published in the Federal Register on
January 18, 2001 (66 FR 96570).
Recently, provider and medical groups have suggested that CAHs may
be at risk of losing the ability to provide access to appropriate
surgical services without the full support of available CRNAs. They
indicated that the existing regulations place the responsibility of the
preanesthesia and postanesthesia evaluations on the operating
practitioner, thereby creating a higher standard for CAHs than for
other hospitals.
In an effort to eliminate or minimize potential access issues in
rural areas and to recognize the CAH's program expansion, in the May 4,
2001 proposed rule, we proposed to revise Sec. 485.639(b) to allow
CRNAs to perform preanesthesia and postanesthesia evaluations in a CAH.
As with any licensed independent health care provider, the proposed
change would not permit CRNAs to practice beyond his or her licensed
scope of practice or
[[Page 39925]]
the approved policies and procedures of the CAH.
We received 26 comments on our proposal.
Comment: Almost all of the 26 commenters supported our proposed
change to the existing CAH conditions of participation to remove the
requirement that only physicians can perform the preanesthesia and
postanesthesia evaluations. The proposed regulation includes CRNAs
among the practitioners that may perform these services. The commenters
stated that the existing anesthesia evaluation requirements for CAHs
are more restrictive than the requirements for hospitals and they
impose an unnecessary burden on operating surgeons and the facilities.
Response: We appreciate the commenters' support.
Comment: One commenter stated that the proposed amendment to the
condition of participation for surgical services under Sec. 485.639(b)
is ill-advised and should not be adopted, or, at the very least, should
be postponed until the regulation regarding physician supervision of
CRNAs in hospitals is finalized.
Response: The commenter correctly notes that we have not finalized
the regulation to amend the physician supervision requirement for CRNAs
(66 FR 96570, January 18, 2001). Our proposal that CRNAs perform
preanesthesia and postanesthesia evaluations in CAHs in our May 4, 2001
proposed rule does not conflict with the January 18, 2001 proposed
physician supervision regulation because our proposal does not affect
current requirements for CRNAs, such as physician supervision. We
mentioned the proposed physician supervision regulation in the preamble
to the May 4 proposed rule as an example of our continual effort to
review and evaluate our policies and regulations to better facilitate
patient access and improve patient outcomes.
Comment: One commenter stated that there is no basis for us to
assume that the safety-oriented anesthesia standards for CAHs should be
any less stringent than those applicable to ambulatory surgical centers
(ASCs).
Response: We acknowledge the commenter's concern regarding the
anesthesia risk and evaluation standard for ASCs. Our existing
conditions for coverage for ASCs require examination of patients by a
physician immediately before surgery to evaluate the risk of anesthesia
and of the procedure to be performed. The ASC conditions for coverage
also require evaluation of patients by a physician for proper
anesthesia recovery prior to discharge from the ASC. We expect to
review and modify the ASC condition of coverage, including the current
anesthesia risk and evaluation standard, through a notice of proposed
rulemaking in 2002. At that time, we will consider the commenter's
concern.
Comment: One commenter stated that according to a recent national
survey of one-third of rural hospital chief executives, almost 80
percent of the respondents reported that their institutions perform
high-complexity surgery, such as gall bladder and stomach surgery. The
commenter further stated that the hospital conditions of participation
require that the preoperative evaluation be conducted by an individual
qualified to administer anesthesia, but in the cases of a nurse
anesthetist, the anesthesia provider must work under the supervision of
the operating practitioner or an anesthesiologist. As such, the
commenter summarized that the hospital requirements are not less
stringent than the CAH requirements.
Response: The commenter has misunderstood the proposal to mean that
physician supervision for CRNAs is eliminated. The proposed regulation,
as noted in response to a previous comment, will not remove physician
supervision of CRNAs.
Unlike in acute care hospitals, CRNAs are currently listed among
the qualified practitioners who can administer anesthesia under
physician supervision in CAHs but they cannot perform the preanesthesia
and postanesthesia evaluations. In response to the provider industry's
concerns with access to care, our proposal was that CRNAs be allowed to
perform preanesthesia and postanesthesia evaluations.
We are adopting the proposed Sec. 485.639(b) as final without
change.
7. Clarification of Location Requirements for CAHs (Secs. 485.610(b)
and (c))
Under section 1820(c)(2)(B)(i) of the Act, a facility seeking
designation by the State as a CAH must meet two distinct types of
location requirements. First, the facility must either be actually
located in a county or equivalent unit of local government in a rural
area, as defined in section 1886(d)(2)(D) of the Act, or it must be
located in an urban area as defined in section 1886(d)(2)(D) of the
Act, but be treated as being located in a rural area under section
1886(d)(8)(E) of the Act. Second, the facility must also be located
more than a 35-mile drive (or, in the case of mountainous terrain or in
areas with only secondary roads available, a 15-mile drive) from a
hospital or similar facility described in section 1820(c) of the Act,
or it must be certified by the State as being a necessary provider of
health care services to residents in the area. Implementing regulations
for these provisions were published in an interim final rule with
comment period in the Federal Register on August 1, 2000 (65 FR 47026)
and are set forth at Sec. 485.610(b).
As we indicated in the May 4 proposed rule, recently, concern has
been expressed that Sec. 485.610(b) does not accurately reflect the
fact that a facility may satisfy the ``rural location'' requirement
either by actually being located in a rural area or by being located in
an urban area but qualifying for treatment as rural under section
1886(d)(8)(E) of the Act. In addition, we have received questions as to
whether a potential CAH must meet both the rural location requirement
and the requirement for location relative to other facilities (or
certification by the State as a ``necessary provider'').
To avoid any further confusion, and ensure that our regulations
reflect the provisions of the law accurately, we proposed to revise
Sec. 485.610(b) to clarify that a potential CAH must either be actually
located in a rural area, or be treated as being rural under section
1886(d)(8)(E) of the Act. In addition, we proposed to place the
provisions of the existing Sec. 485.610(b)(5) in a newly created
paragraph (c) entitled, ``Location relative to other facilities or
necessary provider certification''. We proposed to relocate this
provision in order to clarify that these criteria are separate from the
rural location criteria. These changes do not reflect any change in
policy; they are merely an attempt to improve the clarity of the
regulations.
We did not receive any comments on these proposed changes and,
therefore, are adopting them as final.
8. Other Legislative Changes Affecting CAHs
a. 96-hour Average Length of Stay Standard (Section 403(a) of Public
Law 106-113 and 42 CFR 485.620(b))
As stated in the August 1, 2000 interim final rule with comment
period, prior to the enactment of Public Law 106-113, section
1820(c)(2)(B)(iii) of the Act limited CAH designation only to
facilities that provided inpatient care to each patient for a period of
time not to exceed 96 hours, unless a longer period was required
because of inclement weather or other emergency conditions, or a peer
review organization (PRO) or equivalent entity, on request, waived the
96-hour restriction. Section 403(a) of
[[Page 39926]]
Public Law 106-113 amended section 1820(c)(2)(B)(iii) of the Act to
require that the 96-hour limit on stays be applied on an annual average
basis, and to delete the provisions regarding waiver of longer stays.
Therefore, CAHs will be permitted to keep some individual patients more
than 96 hours without a waiver request, so long as the facility's
average length of acute stays in any 12-month cost reporting period is
not more than 96 hours.
The effective date of this provision is November 29, 1999.
In the August 1, 2000 interim final rule with comment period, we
revised the regulations on conditions of participation for length of
stay for CAHs at Sec. 485.620(b) to reflect this change.
Comment: One commenter noted that 96-hour length of stay limitation
for CAHs clearly contemplates that the facility-wide average length of
stay be computed as an hourly average, while Medicare cost report
instructions require inpatient utilization to be reported by days of
care rather than hours. The commenter expressed concern that if cost
report data on days of care are converted to an hourly equivalent, this
might overstate the length of stay for some facilities, since patients
in the facility for only a few hours might be counted as having been
inpatients for a full 24 hours. The commenter requested that we provide
further directions to the fiscal intermediaries on the exact data to be
used and the precise method to capture the length of stay average.
Response: We understand the commenter's concern and will ensure
that any directions to intermediaries and State agencies on determining
facility-wide average length of stay provide for calculating that
average accurately. However, no change is needed to the proposed
regulation and we are adopting it as final.
b. For-Profit Facilities (Section 403(b) of Public Law 106-113 and 42
CFR 485.610(a))
As stated in the August 1, 2000 interim final rule with comment
period, prior to enactment of Public Law 106-113, section 1820(c)(2)(B)
of the Act allowed only nonprofit or public hospitals to be designated
as CAHs. Section 403(b) of Public Law 106-113 revises section
1820(c)(2)(B) of the Act to remove the words ``nonprofit or public''
before ``hospitals'', thus enabling for-profit hospitals to qualify for
CAH status.
In that interim final rule with comment period, we revised the
regulations on the conditions of participation related to the status
and location for CAHs at Sec. 485.610(a) to reflect this change.
We did not receive any comments on this provision and are adopting
the revision to Sec. 485.610(a) as final.
c. Closed and Downsized Hospitals (Section 403(c) of Public Law 106-113
and 42 CFR 485.610(a)(1))
Under section 1820(c)(2) of the Act, CAH designation was available
only to facilities currently operating as hospitals. As stated in the
August 1, 2000 interim final rule with comment period, section 403(c)
of Public Law 106-113 amended the statute to permit a State to
designate as a CAH a facility that previously was a hospital but ceased
operations on or after November 29, 1989 (10 years prior to the
enactment of Public Law 106-113), if that facility fulfills the
criteria under section 1820(c)(2)(B) of the Act for CAH designation as
of the effective date of its designation. The amendment also allows CAH
designation for facilities that previously had been hospitals, but are
currently State-licensed health clinics or health centers if they meet
the revised criteria for designation under section 1820(c)(2) of the
Act as of the effective date of designation. In the August 1 interim
final rule with comment period, we revised the CAH criteria for State
certification under regulations at Sec. 485.610(a)(1) to reflect this
change.
Although we received no public comment on the revision to
Sec. 485.610(a)(1), we have determined that one technical revision to
Sec. 486.610 is needed. We are making a technical correction to
paragraph (a)(2) of Sec. 485.610. Currently, that paragraph states that
a closed facility may qualify for designation as a CAH only if it meets
applicable criteria for designation under Subpart F of Part 485 ``as of
November 29, 1999.'' However, under section 1820(c)(2)(C)(ii) of the
Act, as added by section 403(c)(2) of Public Law 106-113, the facility
must meet all other applicable requirements for CAH designation by the
State as of the effective date of its designation as a CAH. Therefore,
we are revising Sec. 485.610(a)(2) to state that a closed facility may
qualify for designation as a CAH only if it meets applicable criteria
for designation under Subpart F of Part 485 as of the effective date of
that designation.
In the August 1, 2000 final rule (65 FR 47052), we revised
Sec. 485.610 to reflect the provisions of section 403(c) of Public Law
106-113. However, we inadvertently did not make a conforming change to
Sec. 485.612, which continues to state that the applicant facility must
be a hospital with a provider agreement to participate in the Medicare
program at the time it applies for designation as a CAH. To correct
this oversight and reflect the provisions of section 403(c) in the
regulations at Sec. 485.612, in the June 13, 2001 interim final rule
with comment period (66 FR 32183), we revised Sec. 485.612 to state
that the requirement to have a provider agreement as a hospital at the
time of application does not apply to recently closed facilities as
described in Sec. 485.610(a)(2) or to health clinics or health centers
as described in Sec. 485.610(a)(3).
We did not receive any comments on this provision and are adopting
the provisions as final without change.
d. Elimination of Coinsurance for Clinical Diagnostic Laboratory Tests
Furnished by a CAH (Secs. 410.152 and 413.70))
As we indicated in both the August 1, 2000 and June 13, 2001
interim final rules with comment period, under the law in effect before
the enactment of Public Law 106-113, clinical diagnostic laboratory
services furnished by a CAH to its outpatients were, like other
outpatient CAH services, paid for on a reasonable cost basis, subject
to the Part B deductible and coinsurance provisions. With respect to
coinsurance, this meant that the beneficiary was responsible for
payment of 20 percent of the CAH's customary charges for the services
and the CAH received payment from the Medicare program equal to 80
percent of its reasonable costs of furnishing the services.
In the August 1, 2000 interim final rule with comment period (65 FR
47042), we implemented section 403(e) of Public Law 106-113, which
amended section 1833(a) of the Act and eliminated the Part B
coinsurance and deductible for laboratory tests furnished by a CAH on
an outpatient basis. Thus, CAHs were not permitted to impose a
deductible or coinsurance charge on the beneficiary for these services.
Also, in accordance with section 1833(a)(1)(D) and (a)(2)(D), as also
amended by section 403(e) of Public Law 106-113, Medicare Part B was to
pay 100 percent of the least of the amount determined under the local
laboratory fee schedule, the national limitation amount for that test,
or the amount of the charges billed for the tests.
The effect of this change was that clinical diagnostic laboratory
tests furnished by a CAH to its outpatients, were paid for on the same
basis as clinical diagnostic laboratory tests furnished by full-service
hospitals to outpatients. Section 403(e)(2) of Public
[[Page 39927]]
Law 106-113 provided that this provision was effective with respect to
services furnished on or after November 29, 1999. In the August 1, 2000
interim final rule with comment period, we clarified our policy and
incorporated the provisions of section 403(e) of Public Law 106-113 in
Secs. 410.152 and 413.70 of the regulations.
As we indicated in the June 13, 2001 interim final rule with
comment period (66 FR 32172), section 201(a) of Public Law 106-554
amended section 1834(g) of the Act to provide that there will be no
collection of coinsurance, deductible, copayments, or any other type of
cost sharing from Medicare beneficiaries with respect to outpatient
clinical diagnostic laboratory services in a CAH.
Section 201(a) further provided that payment for these services
will be made on a reasonable cost basis. Section 201(b) of the Public
Law 106-554 amended section 1833(a) of the Act by eliminating any
reference to CAHs receiving payment for outpatient clinical diagnostic
laboratory services on a fee schedule basis. These amendments are
effective for services furnished on or after November 29, 1999.
In the June 13 interim final rule with comment period, we
incorporated the provisions of section 201 of Public Law 106-554 in
Sec. 413.70 of the regulations and changed the references cited in
Sec. 410.152(k)(2). To prevent any misunderstanding of the scope of
section 201(a), we further revised Sec. 413.70(b)(3)(iii) to clarify
that payment to a CAH for clinical diagnostic laboratory tests for
individuals who are not inpatients of the CAH will be made on a
reasonable cost basis only if the individuals are outpatients of the
CAH at the time the specimens are collected. Outpatient status will be
determined under the definition in Sec. 410.2, which provides that an
``outpatient'' is a person who has not been admitted as an inpatient
but is registered as an outpatient and receives services (rather than
supplies alone) from the CAH.
We indicated that we recognize that CAHs may appropriately function
as reference laboratories, by performing clinical diagnostic laboratory
tests on specimens from persons who do not meet the ``outpatient''
definition but have the specimens drawn at other locations, such as
physician offices. Payment for clinical diagnostic laboratory tests for
these other individuals (that are persons who are not patients of the
CAH when the specimens are collected) will be made in accordance with
the provisions of sections 1833(a)(1)(D) and 1833(a)(2)(D) of the Act.
Comment: One commenter on the August 1, 2000 interim final rule
expressed the view that it was Congress' intent to pay CAHs for
clinical diagnostic laboratory tests for outpatients on the basis of
reasonable costs, not on the basis of a laboratory fee schedule. The
commenter suggested that we develop and implement regulations
permitting reasonable cost payment for these laboratory services.
Response: As explained earlier, section 201(a) of Public Law 106-
554 subsequently modified the Medicare law to clearly require
reasonable cost payment for those services and we have implemented that
provision in the June 13, 2001 interim final rule with comment period
(which is being finalized in this final rule).
Comment: Some commenters stated that CAHs frequently perform
clinical diagnostic laboratory tests on specimens drawn from patients
at physician offices, nursing homes, and assisted living facilities in
the community where the CAH is located, and in other rural communities.
The commenters recommended that reasonable cost payment be made to the
CAH for these services because, in the commenters' view, doing so would
help support the provision of health care in these settings.
Response: As explained above and in the preamble to the June 13
interim final rule with comment period, section 201(a) of Public Law
106-554 mandates reasonable cost payment to CAHs for clinical
diagnostic laboratory tests to CAH patients but does not provide
similar payment when the CAH functions as a reference laboratory for
patients who do not come to the CAH but are seen at other locations.
The statute does not provide for such payment for services to non-CAH
patients. We believe these laboratory services provided to individuals
who are not patients of a CAH should be paid for on the same basis as
such services are generally paid for regardless of the fact that the
CAH reference laboratory performed the testing, and that payment for
them on a reasonable cost basis would extend the CAH payment
methodology far beyond the CAH itself. Thus, we are not adopting the
commenters' recommendation.
Comment: One commenter suggested that we not require CAHs to refund
coinsurance amounts collected from beneficiaries and third-party payers
for clinical diagnostic laboratory tests furnished to outpatients on or
after November 29, 1999. The commenter stated that this would be
appropriate because there has been confusion among some CAHs as to
their responsibilities in this area, and returning these amounts could
be burdensome for the CAHs.
Response: Public Law 106-554 clearly and consistently states that,
effective November 29, 1999, these services are not subject to
deductible or coinsurance amounts. Medicare Intermediary Manual
Transmittal No. 1799 and Medicare Hospital Manual Transmittal No. 757,
issued in June 2000, reemphasized this point. Therefore, we are not
making any change in this final rule based on this comment.
e. Assistance With Fee Schedule Payment for Professional Services Under
All-Inclusive Rate
Prior to enactment of Public Law 106-113, section 1834(g) of the
Act provided that the amount of payment for outpatient CAH services
would be the reasonable costs of the CAH in providing such services.
However, the reasonable costs of the CAH's services to outpatients
included only the CAH's costs of providing facility services, and did
not include any payment for professional services. Physicians and other
practitioners who furnished professional services to CAH outpatients
billed the Part B carrier for these services and were paid under the
physician fee schedule in accordance with the provisions of section
1848 of the Act.
In the August 1, 2000 final rule (65 FR 47100), we implemented
section 403(d) of Public Law 106-113, which amended section 1834(g) of
the Act to permit the CAH to elect to be paid for its outpatient
services under an optional method. CAHs making this election would be
paid amounts equal to the sum of the following costs, less the amount
that the hospital may charge as described in section 1866(a)(2)(A) of
the Act (that is, Part A and Part B deductibles and coinsurance
amounts):
For facility services, not including any services for
which payment may be made as outpatient professional services, the
reasonable costs of the CAH in providing the services; and
For professional services otherwise included within
outpatient CAH services, the amounts that would otherwise be paid under
Medicare if the services were not included as outpatient CAH services.
Section 403(d) of Public Law 106-113 added section 1834(g)(3) to
the Act to further specify that payment amounts under this optional
method are to be determined without regard to the amount of the
customary or other charge. The amendment made by
[[Page 39928]]
section 403(d) was effective for cost reporting periods beginning on or
after October 1, 2000.
In the June 13, 2001 interim final rule with comment period (66 FR
32172), we implemented section 202 of Public Law 106-554, which amended
section 1834(g) of the Act to provide that when a CAH elects the option
to be paid for Medicare outpatient services under the reasonable costs
for facility services plus fee schedule amounts for professional
services method, Medicare will pay 115 percent of the amount it would
otherwise pay for the professional services. This provision is
effective for items and services furnished on or after July 1, 2001.
In the June 13 interim final rule with comment period, we revised
the regulations at Sec. 413.70(b)(3) to reflect the change in the level
of payment for professional services under the alternative payment
method for outpatient CAH services.
Comment: One commenter asked for an explanation of the relationship
between payment to CAHs for CRNA services to outpatients at 115 percent
of the amounts that would otherwise be payable under the physician fee
schedule, and the pass-through of CRNA services costs under
Sec. 412.113(c) as described in the proposed rule published on May 4,
2001 (66 FR 22646).
Response: Under the proposed changes to Secs. 413.70 and 412.113(c)
that we included in our May 4, 2001 proposed rule, a CAH would be able
to qualify for the CRNA pass-through (that is, reasonable costs payment
for its costs of compensating CRNAs for their professional services to
inpatients and outpatients) on the same basis as a hospital. If a
particular CAH qualified for the CRNA pass-through and chose to claim
payment under that method for its CRNA compensation costs, it would be
paid on a reasonable cost basis for those costs. However, neither the
CAH nor the individual CRNAs would then be permitted to bill under the
physician fee schedule for any CRNA services to CAH patients. In
particular, if the CAH chose the elective (115 percent) method of
payment for professional services to CAH outpatients, its billings for
those services could not include any amounts for CRNA services.
If a CAH was not qualified for the CRNA pass-through (because, for
example, it furnished 500 or more surgical procedures requiring
anesthesia per year), or was qualified but chose not to claim payment
under the pass-through method, but did choose payment for professional
services to CAH outpatients under the elective (115 percent) method,
payment for CRNA services to outpatients would be made under the
elective (115 percent) method. Under these circumstances, the CAH could
not claim any CRNA compensation costs for the services on its cost
report.
Comment: One commenter asked whether payment under the optional
method described in Sec. 413.70(b)(3) is available for all professional
services to CAH outpatients in CAH space, including professional
services the commenter described as ``clinic visits''.
Response: The optional method applies to professional services
otherwise included within outpatient CAH services provided to CAH
outpatients. Outpatient CAH services are those medical and other
services furnished by a CAH on an outpatient basis. Services that are
not otherwise provided in a CAH on an outpatient basis, such as
services provided by a home health agency owned or operated by a CAH,
are paid under the payment rules applicable to the specific provider or
supplier type and cannot be made under the optional method of payment
for outpatient CAH services.
Comment: One commenter asked whether physicians and other
practitioners who would otherwise be permitted to bill the Medicare
Part B carrier for their professional services provided to CAH patients
could reassign their Part B billing rights for those services to the
CAH under the existing reassignment rules.
Response: The commenter is correct in understanding that
practitioners may reassign their billing rights for professional
services provided to CAH patients under applicable reassignment rules.
Such reassignment would be needed to help ensure that there is not
duplicate billing for those services.
Comment: One commenter stated that our current manual instructions
require all professional services to the outpatients of a particular
CAH to be billed under either the method in Sec. 413.70(b)(2)
(reasonable costs for facility services, with billing by the
practitioner to the carrier for professional services) or the optional
method in Sec. 413.70(b)(3) (reasonable costs for facility services
with billing by the CAH for professional services). The commenter asked
whether a CAH would be permitted to elect the Sec. 413.70(b)(3) method
on a practitioner-by-practitioner basis, so that some practitioners'
services would be billed by the CAH while others would be billed by the
practitioner.
Response: We appreciate the commenter's request and note that we
have already addressed this issue in our regulations. Specifically, the
regulations at Sec. 413.70(b)(3)(i) state that once a CAH elects the
optional method for payment of outpatient CAH services for a cost
reporting period, the optional payment method remains in effect for all
of that period and applies to all outpatient CAH services furnished to
outpatients of the CAH during that period.
Comment: Some commenters noted that section 202 of Pubic Law 106-
554 makes the 115 percent payment option for professional services to
CAH outpatients available for services furnished on or after July 1,
2001. However, the commenters also stated that our program instructions
state that the systems changes needed to permit payment at that level
will not be available before October 1, 2001. The commenters asked for
confirmation that the payment at the 115 percent level for services
furnished on or afterJuly 1, 2001, will be made available to CAHs
electing payment under the optional method, and suggested various
alternatives, including possible retroactive payment adjustments by the
intermediary, by which this could be accomplished.
Response: We appreciate the commenters' suggestions. We will
continue to explore all feasible approaches to ensuring that payment is
made in accordance with statutory requirements and will consider the
various suggestions made by the commenter as we work to achieve this
result.
f. Conforming Change--Conditions of Participation Relating to
Compliance With Hospital Requirements at Time of Application for CAH
Designation (Sec. 485.612)
Under the law in effect prior to enactment of Public Law 106-113,
CAH status was available to facilities only if they were hospitals at
the time of their application for designation as CAHs. This requirement
was implemented through regulations at Sec. 485.610 (Condition of
participation: Status and limitations) and Sec. 485.612 (Condition of
Participation: Compliance with hospital requirements at time of
application). As we previously noted, section 403(c) of Public Law 106-
113 added subparagraphs (C) and (D) to section 1820(c)(2) of the Act to
specify that recently closed facilities and facilities that had
downsized from hospital status to being a clinic or health center would
also be eligible to apply for CAH designation.
As noted earlier, in the August 1, 2000 final rule(65 FR 47052), we
revised our regulations at Sec. 485.610 to reflect the provisions of
section 403(c) of the
[[Page 39929]]
Public Law 106-113. However, we inadvertently did not make a conforming
change to Sec. 485.612, which continues to state that the applicant
facility must be a hospital with a provider agreement to participate in
the Medicare program at the time it applies for designation as a CAH.
To correct this oversight and reflect the provisions of section 403(c)
in the regulations at Sec. 485.612, in the June 13, 2001 interim final
rule with comment period(66 FR 32183), we revised Sec. 485.612 to state
that the requirement to have a provider agreement as a hospital at the
time of application does not apply to recently closed facilities as
described in Sec. 485.610(a)(2) or to health clinics or health centers
as described in Sec. 485.610(a)(3).
We did not receive any comments on this regulation revision and are
adopting it as final.
g. Participation in Swing-Bed Program (Section 403(f) of Public Law
106-113)
Section 403(f) of Public Law 106-113, entitled ``Improvements in
the Critical Access Hospital Program,'' included a provision on swing-
bed agreements. In the August 1, 2000 interim final rule with comment
period, we indicated that since our existing regulations at
Sec. 485.645 already provide for swing beds in CAHs, we were not making
any changes to our regulations based on this provision.
We did not receive any comments on this provison and are adopting
our interim decision not to make any changes to our regulations as
final.
C. Hospital Swing Bed Program
In the August 1, 2000 interim final rule with comment period (65 FR
47042), we indicated that section 408(a) of Public Law 106-113 amended
section 1883(b) of the Act to remove the provision that in order for a
hospital to enter into an agreement to provide Medicare post-hospital
extended care services, the hospital had to be granted a certificate of
need for the provision of long-term care services from the State health
planning and development agency (designated under section 1521 of the
Public Health Service Act) for the State in which the hospital is
located. Section 408(b) of Public Law 106-113 amended section 1883(d)
of the Act to remove the provisions under paragraphs (d)(2) and (d)(3)
that placed restrictions on lengths of stays in hospitals with more
than 49 beds for post-hospital extended care services. These provisions
are effective on the first day after the expiration of the transition
period under section 1888(e)(2)(E) of the Act for payment for covered
skilled nursing facility (SNF) services under the Medicare program;
that is, at the end of the transition period for the SNF prospective
payments system that began with the facility's first cost reporting
period beginning on or after July 1, 1998 and extend through the end of
the facility's third cost reporting period after this date.
The Medicare regulations that implemented the provision of section
1883(b) of the Act are located at Sec. 482.66(a)(3). The regulations
that implemented the provisions of sections 1883(d)(2) and (d)(3) of
the Act are located at Secs. 482.66(a)(6) and (a)(7). As a result of
the changes made by section 408(a) and (b) of Public Law 106-113, in
the August 1, 2000 interim final rule with comment period, we removed
Secs. 482.66(a)(3), (a)(6), and (a)(7). (Existing paragraphs (a)(4) and
(a)(5) were redesignated as (a)(3) and (a)(4), respectively, as a
result of the removal of existing paragraph (a)(3).)
We did not receive any comments on our revisions to the regulations
in the interim final rule with comment period and are adopting them as
final.
VII. MedPAC Recommendations
On March 1, 2001, the Medicare Payment Advisory Commission (MedPAC)
issued its annual report to Congress, including several recommendations
related to the inpatient operating payment system. Those related to the
inpatient prospective payment systems included: accounting for new
technology in hospital prospective payment systems, implementation of
an occupational-mix adjusted wage index for FY 2005, financial
performance and inpatient payment issues, and elimination of the
weighting factors for direct GME for specialties with training beyond
the initial residency period. In the May 4, 2001 proposed rule, we
responded to these recommendations (66 FR 22713-22714).
In addition, we addressed Recommendation 5A concerning the update
factor for inpatient hospital operating costs and for hospitals and
hospital distinct-part units excluded from the prospective payment
system in Appendix D to the proposed rule (and in Appendix C of this
final rule).
A. Accounting for New Technology in Hospital Prospective Payment
Systems (Recommendations 3D and 3E)
Recommendation 3D: For the inpatient payment system, the Secretary
should develop formalized procedures for expeditiously assigning codes,
updating relative weights, and investigating the need for patient
classification changes to recognize the costs of new and substantially
improved technologies.
Response: Section 533 of Public Law 106-554 directs the Secretary
to develop a mechanism for ensuring adequate payment under the hospital
inpatient prospective payment system for new medical services and
technologies, and to report to Congress on ways to more expeditiously
incorporate new services and technologies into that system. The
discussion relating to new medical services and technologies was
included in section II.D. of the May 4, 2001 proposed rule.
MedPAC states that a more formal system for assigning codes and
investigating the need for DRG changes would have enabled the current
system to more adequately respond to new technology. Although we
believe the current process for assigning new codes has the advantage
of being well-understood, we proposed a new process in the May 4
proposed rule. We will be finalizing this process in a separate final
rule.
Recommendation 3E: Additional payments in the inpatient payment
system should be limited to new or substantially improved technologies
that add significantly to the cost of care in a diagnosis related group
and should be made on a budget-neutral basis.
Response: Section 533 of Public Law 106-554 directed the Secretary
to establish a mechanism by October 1, 2001. We will be finalizing this
process in a separate final rule.
B. Occupational-Mix Adjusted Wage Index for FY 2005 (Recommendation 4)
Recommendation: To implement an occupation-mix adjusted wage index
in FY 2005, the Secretary should collect data on wage rates by
occupation in the fiscal year 2002 Medicare cost reports. Hospital-
specific wage rates for each occupation should be supplemented by data
on the mix of occupations for each provider type. The Secretary also
should continue to improve the accuracy of the wage index by
investigating differences in wages across areas for each type of
provider and in the substitution of one occupation for another.
Response: In the May 4 proposed rule, we proposed to collect
occupational mix data from hospitals through a supplemental survey to
the cost report for cost reporting periods beginning during FY 2001. A
more complete discussion of the proposed methodology in the May 4
proposed rule (66 FR 22674) and the public comments we received and our
responses can be found in section III.C.3. of this final rule.
[[Page 39930]]
C. Financial Performance and Inpatient Payment Issues (Recommendations
5B, 5C, and 5D)
Recommendation 5B: In collecting sample patient-level data, CMS
should seek to balance the goals of minimizing payment errors and
furthering understanding of the effects of coding on case-mix change.
Response: The sample data referred to by MedPAC is the Payment
Error Prevention Program (PEPP) Surveillance Sample. These data are
collected to monitor the payment error rate for Medicare inpatient
prospective payment system services and provide outcome data to measure
PROs' performance in reducing payment errors in their respective
States. This information can be appropriately weighted to reflect the
true distribution of DRGs nationally. The sample data supplant the DRG
validation sample that MedPAC used in its original 1996 through 1998
estimates. The current PEPP Surveillance Sample doubles the size of the
earlier DRG validation sample. It is comprised of approximately 60,000
cases per year. We believe this is a sufficient number of cases to both
monitor case-mix index changes and PRO performance on payment error
reduction.
Recommendation 5C: Although the Benefits Improvement and Protection
Act of 2000 improved the equity of the hospital disproportionate share
adjustment, Congress still needs to reform this adjustment by:
Including the costs of all poor patients in calculating
low-income shares used to distribute disproportionate share payments;
and
Using the same formula to distribute payments to all
hospitals covered by prospective payment.
Response: CMS is participating in a Medicare Technical Advisory
Group workgroup concerning technical issues related to the collection
of uncompensated care data relative to the Medicare disproportionate
share formula. A worksheet and instructions to collect these data will
be sent out for prior consultation this summer for revisions to the
cost reports applicable for cost reporting periods beginning on or
after October 1, 2001.
Recommendation 5E: The Congress should protect urban hospitals from
the adverse effect of nearby hospitals being reclassified to areas with
higher wage indexes by computing each area's wage index as if none of
the hospitals located in the area had been reassigned.
Response: In the May 4 proposed rule as in this final rule, CMS
includes the wage data for a reclassified hospital in both the area to
which it is reclassified and the area where the hospital is physically
located. We agree with MedPAC and believe that this will provide
consistency and predictability in hospital reclassification and wage
indices.
D. Specialties With Training Beyond the Initial Residency Period
(Recommendation 10)
Recommendation: The Congress should eliminate the weighting factors
that currently determine Medicare's direct graduate medical education
payments and count all residencies equally through completion of
residents' first specialty or combined program and subspecialty if one
is pursued. Residents training longer than the minimum number of years
required for board eligibility in a specialty, combined program, or
subspecialty should not be included in hospitals' direct graduate
medical education resident counts. These policy changes should be
implemented in a budget-neutral manner through adjustments to the per
resident payment amounts.
Response: Currently, Medicare payments to hospitals for direct GME
is dependent, in part, on the initial residency period of the
residents. Generally, the initial residency period is defined at
Sec. 413.86(g)(1) as the minimum number of years required for board
eligibility, not to exceed 5 years. For purposes of determining the
direct GME payment, residents are weighted at 1.0 FTE within the
initial residency period, and at .5 FTE beyond the initial residency
period. The limitation on the initial residency period was designed by
Congress to limit full Medicare direct GME payment to the time required
to train in a single specialty.
MedPAC states that Medicare's current direct GME payment policy of
limiting full funding to the first specialty in which a resident trains
provides a disincentive for hospitals to offer training in
subspecialties or combined programs and, therefore, may influence
hospitals' decisions on the types of residents that they train. MedPAC
believes that Medicare should not influence workforce policy and
recommends that the disincentive be removed to make Medicare payments
policies neutral with regard to programs with prerequisites,
subspecialties, and combined programs. Accordingly, MedPAC recommends
that Congress eliminate the weighting factors associated with direct
GME payment so that all residents would be counted for full direct GME
payment through the completion of their first specialty, combined
program, or subspecialty. Residents training beyond the minimum number
of years required for board eligibility in a specialty, combined
program, or subspecialty should not be counted for purposes of the
direct GME payment.
MedPAC also believes that eliminating the weighting factors could
potentially increase Medicare's direct GME payments by approximately 5
to 8 percent. Therefore, MedPAC recommends that hospitals' per resident
amounts (PRAs), which are used to calculate the direct GME payment, be
reduced so that this change can be implemented, to the extent possible,
in a budget-neutral manner. MedPAC explains that, although further
research is needed, it appears that hospitals with substantial
subspecialty training (that is, at least 15 percent of the resident
mix) would likely see a small net increase in payments, despite the
reduction to the PRAs, while hospitals that do not have subspecialty
training would likely see a small decrease in payments.
In response to MedPAC's recommendation, we question MedPAC's
estimate that eliminating the weighting factors could increase Medicare
direct GME payments by only 5 to 8 percent. We believe that
subspecialty training constitutes a significant portion of all GME
programs, and, consequently, the elimination of the weighting factors
could potentially increase payments by far more than 8 percent. If
budget neutrality is to be maintained, this could mean that the
attendant reductions to the PRAs could be much greater than MedPAC
might assume. For those teaching hospitals that have substantial
subspecialty training, there is no guarantee that the decreases in the
PRAs will be offset by the increases in the direct GME payments due to
the elimination of the weighting factors.
While the recommendation would remove the existing disincentive for
training in subspecialties, we believe the reductions to the PRAs,
whether they are minimal or more significant, will be far more
detrimental to the smaller teaching hospitals that have little or no
subspecialty training. Many of these hospitals provide care to
beneficiaries in rural, underserved areas and in nonhospital settings.
We believe these conditions may discourage the expansion of residency
training in these areas. It may be inappropriate to limit the direct
GME funding to such hospitals, considering Congress' initiatives to
encourage residency training in rural, underserved areas and in
nonhospital settings. We also are unclear as to how MedPAC would
implement the proposed reduction to the PRAs. MedPAC did not explain in
[[Page 39931]]
its recommendation how it would propose to do this.
VIII. Other Required Information
A. Requests for Data from the Public
In order to respond promptly to public requests for data related to
the prospective payment system, we have established a process under
which commenters can gain access to 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 4, 2001
proposed rule, we published a list of data files that are available for
purchase (66 FR 22714-22716).
B. Information Collection Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
In the May 4, 2001 proposed rule, we solicited public comments on
each of these issues for the following sections that contain
information collection requirements.
Section 412.230(e)(2)(ii) Criteria for an Individual Hospital Seeking
Redesignation to Another Rural Area or an Urban Area;
Sec. 412.232(d)(2)(ii) Criteria for All Hospitals in a Rural County
Seeking Urban Redesignation; Sec. 412.235 Criteria for All Hospitals in
a State Seeking a Statewide Wage Index; and Revised Sec. 412.273
Withdrawing an Application or Terminating an Approved 3-Year
Reclassification
Proposed Secs. 412.230(e)(2)(ii) and 412.232(d)(2)(ii) specified
that, for hospital-specific data for wage index changes for
redesignations effective beginning FY 2003, the hospital must provide a
3-year average of its average hourly wages using data from the CMS
hospital wage survey used to construct the wage index in effect for
prospective payment purposes. For other data, the hospital must provide
a weighted 3-year average of the average hourly wage in the area in
which the hospital is located and a weighted 3-year average of the
average hourly wage in the area to which the hospital seeks
reclassification. Proposed new Sec. 412.235 specifies that in order for
all prospective payment system hospitals in a State to use a statewide
wage index, the hospitals as a group must submit an application to the
MGCRB for a decision for reclassifications for wage index purposes. The
proposed changes to Sec. 412.273 incorporated proposed revised
procedures for hospitals that request withdraw of their wage index
application or termination of their wage index reclassification.
The final versions of these proposed changes, discussed in detail
in section IV.G. of this final rule, implement sections 304 (a) and (b)
of Public Law 106-554.
The information collection requirements associated with a
hospital's application to the MGCRB for geographic reclassifications,
including reclassifications for wage index purposes and the required
submittal of wage data, that are codified in Part 412 are currently
approved by OMB under OMB Approval Number 0938-0573, with an expiration
date of September 30, 2002.
Section 412.348(g)(9) Exception Payments
As discussed in section V. of the May 4 proposed rule, Medicare
makes special exceptions payments for capital-related costs through the
10th year beyond the end of the capital prospective payment system
transition period for eligible hospitals that complete a project that
meets certain requirements specified in Sec. 412.348. In order to
assist our fiscal intermediaries in determining the end of the 10-year
period in which an eligible hospital will no longer be entitled to
receive special exception payments, we proposed to add a new
Sec. 412.348(g)(9) to require that hospitals eligible for special
exception payments under Sec. 412.348(g) submit documentation to the
intermediary indicating the completion date of their project (the date
the project was put in use for patient care) that meets the project
need and project size requirements outlined in Secs. 412.348 (g)(2)
through (g)(5). We proposed that, in order for an eligible hospital to
receive special exception payments, this documentation would have to be
submitted in writing to the intermediary by the later of October 1,
2001, or within 3 months of the end of the hospital's last cost
reporting period beginning before October 1, 2001, during which a
qualifying project was completed.
Because this provision is expected to affect less than 10 hospitals
on an annual basis, this requirement is not subject to the PRA as
stipulated under 5 CFR 1320.3(c).
In the August 1, 2000 interim final rule with comment period, we
solicited public comments on each of these issues for the following
section that contains information collection requirements.
Section 412.103(b) Special treatment: Hospitals Located in Urban Areas
and That Apply for Reclassification as Rural; Application Requirements
Section 412.103(b) specifies that a facility seeking
reclassification under sections 401 (a) or (b) of Public Law 106-113
must apply in writing to the CMS Regional Office and include
documentation of the criteria on which its request is based. The
application must be mailed; facsimile or other electronic means are not
acceptable.
The hospital's application must include a copy of the State law or
regulation or other authoritative document verifying that the
requesting hospital is situated in an area determined to be rural by
the State or the hospital is considered to be a rural hospital.
We estimate that it will take each hospital approximately 30
minutes to complete the application process. We estimate that
additional time would be needed to collect the required documentation.
This recordkeeping should take no more than approximately 2 hours.
Therefore, the paperwork burden associated with the reclassification
process would add up to an additional 2\1/2\ hours per hospital that
request reclassification under section 401 of Public Law 106-113.
This information collection requirement has been submitted to the
Office of Management and Budget for approval and is not effective until
OMB approves it.
If you have any comments on any of these information collection and
recordkeeping requirements, please mail one original and three copies
within 30 days of the publication date directly to the following:
Centers for Medicare & Medicaid Services, Office of Information
Services, Information Technology Investment Management Group,Division
of HCFA Enterprise Standards,Room N2-14-26,7500 Security
Boulevard,Baltimore, MD
[[Page 39932]]
21244-1850,Attn: John Burke, CMS-1158/31/78-F.
And
Office of Information and Regulatory Affairs, Room 10235, New Executive
Office Building,Washington, DC 20503,Attn: Allison Eydt, HCFA Desk
Officer.
List of Subjects
42 CFR Part 405
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas,X-rays.
42 CFR Part 410
Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Reporting and recordingkeeping requirements,
Rural areas, X-rays.
42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 482
Grant program-health, Hospitals, Medicaid, Medicare, Reporting and
recordkeeping requirements.
42 CFR Part 485
Grant programs-health, Health facilities, Medicaid, Medicare,
Reporting and recordkeeping requirements.
42 CFR Part 486
Health professions, Medicare, Organ procurement, X-rays.
Accordingly, 42 CFR chapter IV is amended as follows:
I. The interim final rule with comment period amending 42 CFR Parts
410, 412, 413, 482, and 485 which was published at 65 FR 47026 on
August 1, 2000, is adopted as a final rule with the following changes:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT
RATES FOR SKILLED NURSING FACILITIES
1. The authority citation for Part 413 is revised to read as
follows:
Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and
(n), 1871, 1881, 1883, and 1886 of the Social Security Act (42
U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n),
1395hh, 1395rr, 1395tt, and 1395ww).
2. Section 413.86 is amended by:
a. Revising the first sentence of the introductory text of
paragraphs (g)(11)(i).
b. Revising the first sentence of the introductory text of
paragraph (g)(11)(ii).
c. Revising paragraph (g)(11)(v)(C).
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(g) * * *
(11) * * *
(i) If an urban hospital rotates residents to a separately
accredited rural track program at a rural hospital(s) for two-thirds of
the duration of the program, the urban hospital may include those
residents in its FTE count for the time the rural track residents spend
at the urban hospital. * * *
(ii) If an urban hospital rotates residents to a separately
accredited rural track program at a rural nonhospital site(s) for two-
thirds of the duration of the program, the urban hospital may include
those residents in its FTE count, subject to the requirements under
paragraph (f)(4) of this section. * * *
(v) * * *
(C) All residents that are included by the hospital as part of its
rural track FTE count (not to exceed its rural track FTE limitation)
must train in the rural area. However, where a resident begins to train
in the rural track program at the urban hospital but leaves the program
before completing the total required portion of training in the rural
area, the urban hospital may count the time the resident trained in the
urban hospital if another resident fills the vacated FTE slot and
completes the training in the rural portion of the rural track program.
An urban hospital may not receive graduate medical education payment
for the time the resident trained at the urban hospital if another
resident fills the vacated FTE slot and first begins to train at the
urban hospital.
* * * * *
II. The interim final rule with comment period amending 42 CFR
Parts 410, 412, 413, and 485 which was published at 66 FR 32172 on June
13, 2001, is adopted as a final rule with the following changes:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for Part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 412.108 is amended by revising paragraph (b) to read as
follows:
Sec. 412.108 Special treatment; Medicare-dependent, small rural
hospitals.
* * * * *
(b) Classification procedures. The fiscal intermediary determines
whether a hospital meets the criterion in paragraph (a) of this
section. A hospital must notify its fiscal intermediary to be
considered for MDH status based on the criterion under paragraph
(a)(1)(iii)(C) of this section. Any hospital that believes it meets
this criterion to qualify as an MDH, based on at least two of the three
most recent audited cost reporting periods, must submit a written
request to its intermediary. The intermediary will make its
determination and notify the hospital within 90 days from the date that
it receives the hospital's request and all of the required
documentation. If a hospital disagrees with an intermediary's
determination, it should notify its intermediary and submit
documentable evidence that it meets the criteria. The intermediary
determination is subject to review under subpart R of part 405 of this
chapter. MDH status is effective 30 days after the date of written
notification of approval. The time required by the intermediary to
review the request is considered good cause for granting an extension
of the time limit for the hospital to apply for such a review.
* * * * *
III. For the reasons set forth in the preamble to this final rule,
42 CFR Chapter IV is amended as set forth below:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
A. Part 405 is amended as set forth below:
1. The authority citation for Part 405 continues to read as
follows:
Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and
1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a),
1395hh, 1395kk, 1395rr, and 1395ww(k), and sec. 353 of the Public
Health Service Act (42 U.S.C. 263a).
2. In Sec. 405.2468, paragraph (f)(6)(ii) is republished and
paragraph (f)(6)(ii)(D) is revised to read as follows.
Sec. 405.2468 Allowable costs.
* * * * *
(f) Graduate medical education. * * *
(6) * * *
[[Page 39933]]
(ii) The following costs are not allowable graduate medical
education costs--
* * * * *
(D) The costs associated with activities described in
Sec. 413.85(h) of this chapter.
* * * * *
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
B. Part 412 is amended as follows:
1. The authority citation for Part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section Sec. 412.2 is amended as follows:
a. The introductory text of paragraph (e) is republished.
b. Paragraph (e)(4) is revised.
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) The acquisition costs of hearts, kidneys, livers, lungs,
pancreas, and intestines (or multivisceral organs) incurred by approved
transplantation centers.
* * * * *
3. Section 412.23 is amended by adding a new paragraph (i) to read
as follows:
Sec. 412.23 Excluded hospitals: Classifications.
* * * * *
(i) Changes in classification of hospitals. For purposes of
exclusions from the prospective payment system, the classification of a
hospital is effective for the hospital's entire cost reporting period.
Any changes in the classification of a hospital are made only at the
start of a cost reporting period.
4. Section 412.25 is amended by adding a new paragraph (f) to read
as follows:
Sec. 412.25 Excluded hospital units: Common requirements.
* * * * *
(f) Changes in classification of hospital units. For purposes of
exclusions from the prospective payment system under this section, the
classification of a hospital unit is effective for the unit's entire
cost reporting period. Any changes in the classification of a hospital
unit is made only at the start of a cost reporting period.
5. Section 412.63 is amended by revising paragraphs (t) and (u) to
read as follows:
Sec. 412.63 Federal rates for inpatient operating costs for fiscal
years after Federal fiscal year 1984.
* * * * *
(t) Applicable percentage change for fiscal years 2002 and 2003.
The applicable percentage change for fiscal years 2002 and 2003 is the
percentage increase in the market basket index for prospective payment
hospitals (as defined in Sec. 413.40(a) of this subchapter) minus 0.55
percentage points for hospitals in all areas.
(u) Applicable percentage change for fiscal year 2004 and for
subsequent fiscal years. The applicable percentage change for fiscal
year 2004 and for subsequent years is the percentage increase in the
market basket index for prospective payment hospitals (as defined in
Sec. 413.40(a) of this subchapter) for hospitals in all areas.
* * * * *
6. Section 412.92 is amended as follows:
a. Paragraph (b)(1)(iii)(A) is amended by revising the phrase ``50
mile radius'' to read ``35 mile radius''.
b. Paragraph (c)(1) is revised.
Sec. 412.92 Special treatment: Sole community hospitals.
* * * * *
(c) Terminology. * * *
(1) The term miles means the shortest distance in miles measured
over improved roads. An improved road for this purpose is any road that
is maintained by a local, State, or Federal government entity and is
available for use by the general public. An improved road includes the
paved surface up to the front entrance of the hospital.
* * * * *
Sec. 412.105 Special treatment: Hospitals that incur indirect costs
for graduate medical education programs.
7. Section 412.105 is amended as follows:
a. The introductory text of paragraph (a) is republished.
b. Paragraph (a)(1) is revised.
c. Paragraph (d)(3)(vi) is revised.
d. A new paragraph (d)(3)(vii) is added.
e. Paragraph (f)(1)(ii)(C) is revised.
f. Paragraph (f)(1)(iii) is revised.
g. Paragraph (f)(1)(v) is amended by adding five sentences at the
end.
h. In paragraph (f)(1)(vii), the reference to ``Sec. 413.86(g)(9)''
is removed and ``Sec. 413.86(g)(12)'' is added in its place.
i. Paragraph (f)(1)(ix) is revised.
Sec. 412.105 Special treatment: Hospitals that incur indirect costs
for graduate medical education programs.
* * * * *
(a) Basic data. CMS determines the following for each hospital:
(1) The hospital's ratio of full-time equivalent residents, except
as limited under paragraph (f) of this section, to the number of beds
(as determined under paragraph (b) of this section). Except for the
special circumstances for affiliated groups and new programs described
in paragraphs (f)(1)(vi) and (f)(1)(vii) of this section, for a
hospital's cost reporting periods beginning on or after October 1,
1997, this ratio may not exceed the ratio for the hospital's most
recent prior cost reporting period after accounting for the cap on the
number of allopathic and osteopathic full-time equivalent residents as
described in paragraph (f)(1)(iv) of this section, and adding to the
capped numerator any dental and podiatric full-time equivalent
residents. The exception for new programs described in paragraph
(f)(1)(vii) of this section applies to each new program individually
for which the full-time equivalent cap may be adjusted based on the
period of years equal to the minimum accredited length of each new
program.
* * * * *
(d) Determination of education adjustment factor. * * *
* * * * *
(3) * * *
(vi) For discharges occurring during fiscal year 2002, 1.6.
(vii) For discharges occurring on or after October 1, 2002, 1.35.
* * * * *
(f) Determining the total number of full-time equivalent residents
for cost reporting periods beginning on or after July 1, 1991. * * *
(1) * * *
(ii) * * *
(C) Effective for discharges occurring on or after October 1, 1997,
the time spent by a resident in a nonhospital setting in patient care
activities under an approved medical residency training program is
counted towards the determination of full-time equivalency if the
criteria set forth in Sec. 413.86(f)(3) or Sec. 413.86(f)(4) of this
subchapter, as applicable, are met.
(iii)(A) Full-time equivalent status is based on the total time
necessary to fill a residency slot. No individual may be counted as
more than one full-time equivalent. If a resident is assigned to
[[Page 39934]]
more than one hospital, the resident counts as a partial full-time
equivalent based on the proportion of time worked in any of the areas
of the hospital listed in paragraph (f)(1)(ii) of this section, to the
total time worked by the resident. A part-time resident or one working
in an area of the hospital other than those listed under paragraph
(f)(1)(ii) of this section (such as a freestanding family practice
center or an excluded hospital unit) would be counted as a partial
full-time equivalent based on the proportion of time assigned to an
area of the hospital listed in paragraph (f)(l)(ii) of this section,
compared to the total time necessary to fill a full-time residency
slot.
(B) The time spent by a resident in research that is not associated
with the treatment or diagnosis of a particular patient is not
countable.
* * * * *
(v) * * * If a hospital qualified for an adjustment to the limit
established under paragraph (f)(1)(iv) of this section for new medical
residency programs created under paragraph (f)(1)(vii) of this section,
the count of residents participating in new medical residency training
programs above the number included in the hospital's FTE count for the
cost reporting period ending during calendar year 1996 is added after
applying the averaging rules in this paragraph (f)(l)(v) for a period
of years. Residents participating in new medical residency training
programs are included in the hospital's FTE count before applying the
averaging rules after the period of years has expired. For purposes of
this paragraph, for each new program started, the period of years
equals the minimum accredited length for each new program. The period
of years for each new program begins when the first resident begins
training in each new program. Subject to the provisions of paragraph
(f)(1)(ix) of this section, FTE residents that are displaced by the
closure of either another hospital or another hospital's program are
added to the FTE count after applying the averaging rules in this
paragraph (f)(l)(v) for the receiving hospital for the duration of time
that the displaced residents are training at the receiving hospital.
* * * * *
(ix) A hospital may receive a temporary adjustment to its full-time
equivalent cap to reflect residents added because of another hospital's
closure if the hospital meets the criteria specified in
Secs. 413.86(g)(8)(i) and (g)(8)(ii) of this subchapter. If a hospital
that closes its residency training program agrees to temporarily reduce
its FTE cap according to the criteria specified in
Secs. 413.86(g)(8)(i) and (g)(8)(iii)(B) of this subchapter, another
hospital(s) may receive a temporary adjustment to its FTE cap to
reflect residents added because of the closure of the residency
training program if the criteria specified in Secs. 413.86(g)(8)(i) and
(g)(8)(iii)(A) of this subchapter are met.
* * * * *
8. Section 412.106 is amended by revising the heading of paragraph
(e) and paragraph (e)(5) to read as follows:
Sec. 412.106 Special treatment: Hospitals that serve a
disproportionate share of low-income patients.
* * * * *
(e) Reduction in payments beginning FY 1998. * * *
(5) For FY 2002, 3 percent.
* * * * *
Sec. 412.113 [Amended]
9. In Sec. 412.113(c), including the heading for paragraph (c), the
term ``hospital'', wherever it appears, is revised to read ``hospital
or CAH'' (16 times).
10. Section 412.230 is amended by a new paragraph (a)(5)(v) and
revising paragraph (e)(2) to read as follows:
Sec. 412.230 Criteria for an individual hospital seeking redesignation
to another rural area or an urban area.
(a) * * *
(5) Limitations on redesignation. * * *
(v) Beginning with wage index reclassification applications for FY
2003, if a hospital is already reclassified to a given geographic area
for wage index purposes for a 3-year period, and submits an application
for reclassification to the same area for either the second or third
year of the 3-year period, that application will not be approved.
* * * * *
(e) Use of urban or other rural area's wage index. * * *
* * * * *
(2) Appropriate wage data. For a wage index change, the hospital
must submit appropriate wage data as follows:
(i) For redesignations effective through FY 2002:
(A) For hospital-specific data, the hospital must provide data from
the CMS hospital wage survey used to construct the wage index in effect
for prospective payment purposes during the fiscal year prior to the
fiscal year for which the hospital requests reclassification.
(B) For data for other hospitals, the hospital must provide data
concerning the average hourly wage in the area in which the hospital is
located and the average hourly wage in the area to which the hospital
seeks reclassification. The wage data are taken from the CMS hospital
wage survey used to construct the wage index in effect for prospective
payment purposes during the fiscal year prior to the fiscal year for
which the hospital requests reclassification.
(C) If the hospital is requesting reclassification under paragraph
(e)(1)(iv)(B) of this section, the hospital must provide occupational-
mix data to demonstrate the average occupational mix for each
employment category in the area to which it seeks reclassification.
Occupational-mix data can be obtained from surveys conducted by the
American Hospital Association.
(ii) For redesignations effective beginning FY 2003:
(A) For hospital-specific data, the hospital must provide a
weighted 3-year average of its average hourly wages using data from the
CMS hospital wage survey used to construct the wage index in effect for
prospective payment purposes.
(B) For data for other hospitals, the hospital must provide a
weighted 3-year average of the average hourly wage in the area in which
the hospital is located and a weighted 3-year average of the average
hourly wage in the area to which the hospital seeks reclassification.
The wage data are taken from the CMS hospital wage survey used to
construct the wage index in effect for prospective payment purposes.
* * * * *
11. Section 412.232 is amended by revising paragraph (d)(2) to read
as follows:
Sec. 412.232 Criteria for all hospitals in a rural county seeking
urban redesignation.
* * * * *
(d) Appropriate data. * * *
* * * * *
(2) Appropriate wage data. The hospitals must submit appropriate
data as follows:
(i) For redesignations effective through FY 2002:
(A) For hospital-specific data, the hospitals must provide data
from the CMS wage survey used to construct the wage index in effect for
prospective payment purposes during the fiscal year prior to the fiscal
year for which the hospitals request reclassification.
(B) For data for other hospitals, the hospitals must provide the
following:
(1) The average hourly wage in the adjacent area, which is taken
from the CMS hospital wage survey used to
[[Page 39935]]
construct the wage index in effect for prospective payment purposes
during the fiscal year prior to the fiscal year for which the hospitals
request reclassification.
(2) Occupational-mix data to demonstrate the average occupational
mix for each employment category in the adjacent area. Occupational-mix
data can be obtained from surveys conducted by the American Hospital
Association.
(ii) For redesignations effective beginning FY 2003:
(A) For hospital-specific data, the hospital must provide a
weighted 3-year average of its average hourly wages using data from the
CMS hospital wage survey used to construct the wage index in effect for
prospective payment purposes.
(B) For data for other hospitals, the hospital must provide a
weighted 3-year average of the average hourly wage in the area in which
the hospital is located and a weighted 3-year average of the average
hourly wage in the area to which the hospital seeks reclassification.
The wage data are taken from the CMS hospital wage survey used to
construct the wage index in effect for prospective payment purposes.
12. Section 412.235 is added to read as follows:
Sec. 412.235 Criteria for all hospitals in a State seeking a statewide
wage index redesignation.
(a) General criteria. For all prospective payment system hospitals
in a State to be redesignated to a statewide wage index, the following
conditions must be met:
(1) All prospective payment system hospitals in the State must
apply as a group for reclassification to a statewide wage index through
a signed single application.
(2) All prospective payment system hospitals in the State must
agree to the reclassification to a statewide wage index through a
signed affidavit on the application.
(3) All prospective payment system hospitals in the State must
agree, through an affidavit, to withdrawal of an application or to
termination of an approved statewide wage index reclassification.
(4) All hospitals in the State must waive their rights to any wage
index classification that they would otherwise receive absent the
statewide wage index classification, including a wage index that any of
the hospitals might have received through individual geographic
reclassification.
(5) New hospitals that open within the State prior to the deadline
for submitting an application for a statewide wage index
reclassification (September 1), regardless of whether a group
application has already been filed, must agree to the use of the
statewide wage index as part of the group application. New hospitals
that open within the State after the deadline for submitting a
statewide wage index reclassification application or during the
approved reclassification period will be considered a party to the
statewide wage index application and reclassification.
(b) Effect on payments.
(1) An individual hospital within the State may receive a wage
index that could be higher or lower under the statewide wage index
reclassification in comparison to its otherwise redesignated wage
index.
(2) Any new prospective payment system hospital that opens in the
State during the effective period of an approved statewide wage index
reclassification will be designated to receive the statewide wage index
for the duration of that period.
(c) Terms of the decision.
(1) A decision by the MGCRB on an application for a statewide wage
index reclassification will be effective for 3 years beginning with
discharges occurring on the first day (October 1) of the second Federal
fiscal year following the Federal fiscal year in which the hospitals
filed a complete application.
(2) The procedures and timeframes specified in Sec. 412.273 apply
to withdrawals of applications for redesignation to a statewide wage
index and terminations of approved statewide wage index
reclassifications, including the requirement that, to withdraw an
application or terminate an approved reclassification, the request must
be made in writing by all hospitals that are party to the application,
except hospitals reclassified into the State for purposes of receiving
the statewide wage index.
13. Section 412.273 is amended as follows:
a. The title of the section is revised.
b. Paragraphs (b) and (c) are redesignated as paragraphs (c) and
(d), respectively.
c. A new paragraph (b) is added.
d. Redesignated paragraph (c) is revised.
Sec. 412.273 Withdrawing an application or terminating an approved 3-
year reclassification.
* * * * *
(b) Request for termination of approved 3-year wage index
reclassifications.
(1) A hospital, or a group of hospitals, that has been issued a
decision on its application for a 3-year reclassification for wage
index purposes only or for redesignation to a statewide wage index and
has not withdrawn that application under the procedures specified in
paragraph (a) of this section may request termination of its approved
3-year wage index reclassification under the following conditions:
(i) The request to terminate must be received by the MGCRB within
45 days of the publication of the annual notice of proposed rulemaking
concerning changes to the inpatient hospital prospective payment system
and proposed payment rates for the fiscal year for which the
termination is to apply.
(ii) A request to terminate a 3-year reclassification will be
effective only for the full fiscal year(s) remaining in the 3-year
period at the time the request is received. Requests for terminations
for part of a fiscal year will not be considered.
(2) Reapplication within the approved 3-year period.
(i) If a hospital elects to withdraw its wage index application
after the MGCRB has issued its decision, it may terminate its
withdrawal in a subsequent fiscal year and request the MGCRB to
reinstate its wage index reclassification for the remaining fiscal
year(s) of the 3-year period.
(ii) A hospital may apply for reclassification for purposes of the
wage index to a different area (that is, an area different from the one
to which it was originally reclassified for the 3-year period). If the
application is approved, the reclassification will be effective for 3
years.
(c) Written request only. A request to withdraw an application or
terminate an approved reclassification must be made in writing to the
MGCRB by all hospitals that are party to the application or
reclassification.
* * * * *
14. Section 412.274 is amended by revising paragraph (b) to read as
follow:
Sec. 412.274 Scope and effect of an MGCRB decision.
* * * * *
(b) Effective date and term of the decision.
(1) A standardized amount classification change is effective for
one year beginning with discharges occurring on the first day (October
1) of the second Federal fiscal year following the Federal fiscal year
in which the complete application is filed and ending effective at the
end of that Federal fiscal year (the end of the next September 30).
(2) A wage index classification change is effective for 3 years
beginning with
[[Page 39936]]
discharges occurring on the first day (October 1) of the second Federal
fiscal year in which the complete application is filed.
* * * * *
15. Section 412.348 is amended by revising paragraph (g)(6) and
adding a new paragraph (g)(9) to read as follows:
Sec. 412.348 Exception payments.
* * * * *
(g) Special exceptions process. * * *
(6) Minimum payment level.
(i) The minimum payment level for qualifying hospitals will be 70
percent.
(ii) CMS will adjust the minimum payment level in one percentage
point increments as necessary to satisfy the requirement specified in
paragraph (h) of this section that total estimated payments under the
exceptions process not exceed 10 percent of the total estimated capital
prospective payment system payments for the same fiscal year.
* * * * *
(9) Notification requirement. Eligible hospitals must submit
documentation to the intermediary indicating the completion date of a
project that meets the project need requirement under paragraph (g)(2)
of this section, the project size requirement under paragraph (g)(5) of
this section, and, in the case of certain urban hospitals, an excess
capacity test under paragraph (g)(4) of this section, by the later of
October 1, 2001 or within 3 months of the end of the hospital's last
cost reporting period beginning before October 1, 2001, during which a
qualifying project was completed.
* * * * *
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT
RATES FOR SKILLED NURSING FACILITIES
C. Part 413 is amended as follows:
1. The authority citation for Part 413 continues 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, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n),
1395hh, 1395rr, 1395tt, and 1395ww).
2. Section 413.70 is amended as follows:
a. Paragraph (a)(1) is republished.
b. A new paragraph (a)(1)(iv) is added.
c. Paragraph (a)(2) is revised.
d. A new paragraph (a)(3) is added.
e. Paragraph (b)(1) is revised.
f. Paragraph (b)(2)(i)(C) is revised.
g. New paragraphs (b)(4), (b)(5) and (b)(6) are added.
Sec. 413.70 Payment for services of a CAH.
(a) Payment for inpatient services furnished by a CAH.
(1) Payment for inpatient services of a CAH is the reasonable costs
of the CAH in providing CAH services to its inpatients, as determined
in accordance with section 1861(v)(1)(A) of the Act and the applicable
principles of cost reimbursement in this part and in Part 415 of this
chapter, except that the following payment principles are excluded when
determining payment for CAH inpatient services:
* * * * *
(iv) The payment window provisions for preadmission services,
specified in Sec. 412.2(c)(5) of this subchapter and Sec. 413.40(c)(2).
(2) Except as specified in paragraph (a)(3) of this section,
payment to a CAH for inpatient services does not include any costs of
physician services or other professional services to CAH inpatients,
and is subject to the Part A hospital deductible and coinsurance, as
determined under subpart G of part 409 of this chapter.
(3) If a CAH meets the criteria in Sec. 412.113(c) of this
subchapter for pass-through of costs of anesthesia services furnished
by qualified nonphysician anesthetists employed by the CAH or obtained
under arrangements, payment to the CAH for the costs of those services
is made in accordance with Sec. 412.113(c).
(b) Payment for outpatient services furnished by CAH.
(1) General.
(i) Unless the CAH elects to be paid for services to its
outpatients under the method specified in paragraph (b)(3) of this
section, the amount of payment for outpatient services of a CAH is the
amount determined under paragraph (b)(2) of this section.
(ii) Except as specified in paragraph (b)(6) of this section,
payment to a CAH for outpatient services does not include any costs of
physician services or other professional services to CAH outpatients.
(2) Reasonable costs for facility services.
(i) * * *
(C) Any type of reduction to operating or capital costs under
Sec. 413.124 or Sec. 413.130(j).
* * * * *
(4) Costs of emergency room on-call physicians.
(i) Effective for cost reporting periods beginning on or after
October 1, 2001, the reasonable costs of outpatient CAH services under
paragraph (b) of this section may include amounts for reasonable
compensation and related costs for an emergency room physician who is
on call but who is not present on the premises of the CAH involved, is
not otherwise furnishing physicians' services, and is not on call at
any other provider or facility.
(ii) For purposes of this paragraph (b)(4)--
(A) ``Amounts for reasonable compensation and related costs'' means
all allowable costs of compensating emergency room physicians who are
on call to the extent the costs are found to be reasonable under the
rules specified in paragraph (b)(2) of this section and the applicable
sections of Part 413. Costs of compensating emergency room physicians
are allowable only if the costs are incurred under written contracts
that require the physician to come to the CAH when the physician's
presence is medically required.
(B) An ``emergency room physician who is on call' means a doctor of
medicine or osteopathy with training or experience in emergency care
who is immediately available by telephone or radio contact, and is
available on site within the timeframes specified in Sec. 485.618(d) of
this chapter.
(5) Costs of ambulance services.
(i) Effective for services furnished on or after December 21, 2000,
payment for ambulance services furnished by a CAH or an entity that is
owned and operated by a CAH is the reasonable costs of the CAH or the
entity in furnishing those services, but only if the CAH or the entity
is the only provider or supplier of ambulance services located within a
35-mile drive of the CAH or the entity.
(ii) For purposes of paragraph (b)(5) of this section, the distance
between the CAH or the entity and the other provider or supplier of
ambulance services will be determined as the shortest distance in miles
measured over improved roads between the CAH or the entity and the site
at which the vehicles of the closest provider or supplier of ambulance
services are garaged. An improved road for this purpose is any road
that is maintained by a local, State, or Federal government entity and
is available for use by the general public. An improved road will be
considered to include the paved surface up to the front entrance of the
hospital and the front entrance of the garage.
(6) If a CAH meets the criteria in Sec. 412.113(c) of this
subchapter for pass-through of costs of anesthesia services furnished
by nonphysician anesthetists employed by the CAH or obtained under
[[Page 39937]]
arrangement, payment to the CAH for the costs of those services is made
in accordance with Sec. 412.113(c) of this chapter.
* * * * *
3. Section 413.86 is amended as follows:
a. Paragraph (e)(4)(ii)(C)(1) is revised.
b. Paragraph (e)(5)(iv) is removed.
c. Paragraph (g)(4) is revised.
d. Paragraph (g)(5) is revised.
e. In paragraph (g)(6), the reference to ``paragraph (g)(9)'' is
removed and ``paragraph (g)(12)'' is added in its place.
f. Paragraph (g)(8) is revised.
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(e) Determining per residents amounts for the base period. * * *
(4) * * *
(ii) * * *
(C) Determining necessary revisions to the per resident amount. * *
*
(1) Floor. (i) For cost reporting periods beginning on or after
October 1, 2000, and before October 1, 2001, if the hospital's per
resident amount would otherwise be less than 70 percent of the
locality-adjusted national average per resident amount for FY 2001 (as
determined under paragraph (e)(4)(ii)(B) of this section), the per
resident amount is equal to 70 percent of the locality-adjusted
national average per resident amount for FY 2001.
(ii) For cost reporting periods beginning on or after October 1,
2001, and before October 1, 2002, if the hospital's per resident amount
would otherwise be less than 85 percent of the locality-adjusted
national average per resident amount for FY 2002 (as determined under
paragraph (e)(4)(ii)(B) of this section), the per resident amount is
equal to 85 percent of the locality-adjusted national average per
resident amount for FY 2002.
(iii) For subsequent cost reporting periods beginning on or after
October 1, 2002, the hospital's per resident amount is updated using
the methodology specified under paragraph (e)(3)(i) of this section.
* * * * *
(g) Determining the weighted number of FTE residents. * * *
(4) For purposes of determining direct graduate medical education
payments--
(i) For cost reporting periods beginning on or after October 1,
1997, a hospital's unweighted FTE count for residents in allopathic and
osteopathic medicine may not exceed the hospital's unweighted FTE count
(or, effective for cost reporting periods beginning on or after April
1, 2000, 130 percent of the unweighted FTE count for a hospital located
in a rural area) for these residents for the most recent cost reporting
period ending on or before December 31, 1996.
(ii) If a hospital's number of FTE residents in a cost reporting
period beginning on or after October 1, 1997, and before October 1,
2001, exceeds the limit described in this paragraph (g), the hospital's
total weighted FTE count (before application of the limit) will be
reduced in the same proportion that the number of FTE residents for
that cost reporting period exceeds the number of FTE residents for the
most recent cost reporting period ending on or before December 31,
1996.
(iii) If the hospital's number of FTE residents in a cost reporting
period beginning on or after October 1, 2001 exceeds the limit
described in this paragraph (g), the hospital's weighted FTE count
(before application of the limit), for primary care and obstetrics and
gynecology residents and nonprimary care residents, respectively, will
be reduced in the same proportion that the number of FTE residents for
that cost reporting period exceeds the number of FTE residents for the
most recent cost reporting period ending on or before December 31,
1996.
(iv) Hospitals that are part of the same affiliated group may elect
to apply the limit on an aggregate basis.
(v) The fiscal intermediary may make appropriate modifications to
apply the provisions of this paragraph (g)(4) based on the equivalent
of a 12-month cost reporting period.
(5) For purposes of determining direct graduate medical education
payment--
(i) For the hospital's first cost reporting period beginning on or
after October 1, 1997, the hospital's weighted FTE count is equal to
the average of the weighted FTE count for the payment year cost
reporting period and the preceding cost reporting period.
(ii) For cost reporting periods beginning on or after October 1,
1998, and before October 1, 2001, the hospital's weighted FTE count is
equal to the average of the weighted FTE count for the payment year
cost reporting period and the preceding two cost reporting periods.
(iii) For cost reporting periods beginning on or after October 1,
2001, the hospital's weighted FTE count for primary care and obstetrics
and gynecology residents is equal to the average of the weighted
primary care and obstetrics and gynecology counts for the payment year
cost reporting period and the preceding two cost reporting periods, and
the hospital's weighted FTE count for nonprimary care residents is
equal to the average of the weighted nonprimary care FTE counts for the
payment year cost reporting period and the preceding two cost reporting
periods.
(iv) The fiscal intermediary may make appropriate modifications to
apply the provisions of this paragraph (g)(5) based on the equivalent
of 12-month cost reporting periods.
(v) If a hospital qualifies for an adjustment to the limit
established under paragraph (g)(4) of this section for new medical
residency programs created under paragraph (g)(6) of this section, the
count of the residents participating in new medical residency training
programs above the number included in the hospital's FTE count for the
cost reporting period ending during calendar year 1996 is added after
applying the averaging rules in this paragraph (g)(5) for a period of
years. Residents participating in new medical residency training
programs are included in the hospital's FTE count before applying the
averaging rules after the period of years has expired. For purposes of
this paragraph (g)(5), for each new program started, the period of
years equals the minimum accredited length for each new program. The
period of years begins when the first resident begins training in each
new program.
(vi) Subject to the regulations at paragraph (g)(8) of this
section, FTE residents that are displaced by the closure of either
another hospital or another hospital's program are added to the FTE
count after applying the averaging rules in this paragraph (g)(5) for
the receiving hospital for the duration of the time that the displaced
residents are training at the receiving hospital.
* * * * *
(8) Closure of hospital or hospital residency program.
(i) Definitions. For purposes of this paragraph (g)(8)--
(A) ``Closure of a hospital'' means the hospital terminates its
Medicare agreement under the provisions of Sec. 489.52 of this chapter.
(B) ``Closure of a hospital residency training program'' means the
hospital ceases to offer training for residents in a particular
approved medical residency training program.
(ii) Closure of a hospital. 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:
(A) The hospital is training additional residents from a hospital
that closed on or after July 1, 1996.
[[Page 39938]]
(B) 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) Closure of a hospital's residency training program. If a
hospital that closes its residency training program voluntarily agrees
to temporarily reduce its FTE cap according to the criteria specified
in paragraph (g)(8)(iii)(B) of this section, another hospital(s) may
receive a temporary adjustment to its FTE cap to reflect residents
added because of the closure of the residency training program if the
criteria specified in paragraph (g)(8)(iii)(A) of this section are met.
(A) Receiving hospital(s). A hospital may receive a temporary
adjustment to its FTE cap to reflect residents added because of the
closure of another hospital's residency training program if--
(1) The hospital is training additional residents from the
residency training program of a hospital that closed a program; and
(2) No later than 60 days after the hospital begins to train the
residents, the hospital submits to its fiscal intermediary a request
for a temporary adjustment to its FTE cap, documents that it is
eligible for this temporary adjustment by identifying the residents who
have come from another hospital's closed program and have caused the
hospital to exceed its cap, specifies the length of time the adjustment
is needed, and submits to its fiscal intermediary a copy of the FTE
reduction statement by the hospital that closed its program, as
specified in paragraph (g)(8)(iii)(B)(2) of this section.
(B) Hospital that closed its program(s). A hospital that agrees to
train residents who have been displaced by the closure of another
hospital's program may receive a temporary FTE cap adjustment only if
the hospital with the closed program--
(1) Temporarily reduces its FTE cap based on the FTE residents in
each program year training in the program at the time of the program's
closure. This yearly reduction in the FTE cap will be determined based
on the number of those residents who would have been training in the
program during that year had the program not closed; and
(2) No later than 60 days after the residents who were in the
closed program begin training at another hospital, submit to its fiscal
intermediary a statement signed and dated by its representative that
specifies that it agrees to the temporary reduction in its FTE cap to
allow the hospital training the displaced residents to obtain a
temporary adjustment to its cap; identifies the residents who were in
training at the time of the program's closure; identifies the hospitals
to which the residents are transferring once the program closes; and
specifies the reduction for the applicable program years.
* * * * *
PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
D. Part 485 is amended as follows:
1. The authority citation for part 485 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and
1395hh).
2. Section 485.610 is amended by revising paragraphs (a)(2)(ii) and
(b) and adding a new paragraph (c) to read as follows:
Sec. 485.610 Condition of participation: Status and location.
(a) * * *
(2) * * *
(ii) Meets the criteria for designation under this subpart as of
the effective date of its designation; or
* * * * *
(b) Standard: Location in a rural area or treatment as rural. The
CAH meets the requirements of either paragraph (b)(1) or (b)(2) of this
section.
(1) The CAH meets the following requirements:
(i) The CAH is located outside any area that is a Metropolitan
Statistical Area, as defined by the Office of Management and Budget, or
that has been recognized as urban under Sec. 412.62(f) of this chapter;
(ii) The CAH is not deemed to be located in an urban area under
Sec. 412.63(b) of this chapter; and
(iii) The CAH has not been classified as an urban hospital for
purposes of the standardized payment amount by CMS or the Medicare
Geographic Classification Review Board under Sec. 412.230(e) of this
chapter, and is not among a group of hospitals that have been
redesignated to an adjacent urban area under Sec. 412.232 of this
chapter.
(2) The CAH is located within a Metropolitan Statistical Area, as
defined by the Office of Management and Budget, but is being treated as
being located in a rural area in accordance with Sec. 412.103 of this
chapter.
(c) Standard: Location relative to other facilities or necessary
provider certification. The CAH is located more than a 35-mile drive
(or, in the case of mountainous terrain or in areas with only secondary
roads available, a 15-mile drive) from a hospital or another CAH, or
the CAH is certified by the State as being a necessary provider of
health care services to residents in the area.
3. Section 485.639 is amended by revising paragraph (b) to read as
follows:
Sec. 485.639 Condition of participation: Surgical services.
* * * * *
(b) Anesthetic risk and evaluation.
(1) A qualified practitioner, as specified in paragraph (a) of this
section, must examine the patient immediately before surgery to
evaluate the risk of the procedure to be performed.
(2) A qualified practitioner, as specified in paragraph (c) of this
section, must examine each patient before surgery to evaluate the risk
of anesthesia.
(3) Before discharge from the CAH, each patient must be evaluated
for proper anesthesia recovery by a qualified practitioner, as
specified in paragraph (c) of this section.
* * * * *
4. Section 485.643 is amended by revising paragraph (f) to read as
follows:
Sec. 485.643 Condition of participation: Organ, tissue, and eye
procurement.
* * * * *
(f) For purposes of these standards, the term ``organ'' means a
human kidney, liver, heart, lung, pancreas, or intestines (or
multivisceral organs).
PART 486--CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED
BY SUPPLIERS
F. Part 486 is amended as follows:
1. The authority citation for Part 486 continues to read as
follows:
Authority: Sections 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 486.302 is amended by revising the definition of
``organ'' to read as follows:
Sec. 486.302 Definitions.
* * * * *
``Organ'' means a human kidney, liver, heart, lung, pancreas, or
intestines (or multivisceral organs).
* * * * *
[[Page 39939]]
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance)
Dated: July 23, 2001.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
Dated: July 24, 2001.
Tommy G. Thompson,
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, 2001 and Update Factors
and Rate-of-Increase Percentages Effective With Cost Reporting
Periods Beginning On or After October 1, 2001
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, 2001, except for
SCHs, MDHs, 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.
SCHs 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, the updated
hospital-specific rate based on FY 1987 cost per discharge, or, if
qualified, 50 percent of the updated hospital-specific rate based on FY
1996 cost per discharge, plus the greater of 50 percent of the updated
FY 1982 or FY 1987 hospital-specific rate or 50 percent of the Federal
DRG payment rate. Section 213 of Public Law 106-554 amended section
1886(b)(3) of the Act to allow all SCHs to rebase their hospital-
specific rate based on their FY 1996 cost per discharge.
Under section 1886(d)(5)(G) of the Act, MDHs 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 Federal
national rate. (See section II.D.3. of this Addendum for a complete
description.)
As discussed below in section II. of this Addendum, we are making
changes in the determination of the prospective payment rates for
Medicare inpatient operating costs for FY 2002. The changes, to be
applied prospectively, affect the calculation of the Federal rates. In
section III. of this Addendum, we finalize changes to the prospective
payment rates for inpatient operating costs for FY 2001, as set forth
in the June 13, 2001 interim final rule with comment period. In section
IV. of this Addendum, we discuss our changes for determining the
prospective payment rates for Medicare inpatient capital-related costs
for FY 2002. 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 2002. 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 2002
The basic methodology for determining prospective payment rates for
inpatient operating costs is set forth at Sec. 412.63. 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 will be effective with discharges occurring on or after
October 1, 2001.
In summary, the standardized amounts set forth in Tables 1A and 1C
of section VI. of this Addendum reflect--
Updates of 2.75 percent for all areas (that is, the market
basket percentage increase of 3.3 percent minus 0.55 percentage
points);
An adjustment to ensure budget neutrality as provided for
under 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 2001 budget
neutrality factor and applying a revised factor;
An adjustment to apply the revised outlier offset by
removing the FY 2001 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 (52 FR 33043, 33066) contains a detailed explanation of how
the target amounts were determined and how they are used in computing
the Puerto Rico rates.
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 (d)(2)(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 cost
variations among hospitals. These effects include case-mix, differences
in area wage levels, cost-of-living adjustments for Alaska and Hawaii,
indirect medical education (IME) costs, and costs 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
[[Page 39940]]
reflect the proportion of discharges in large urban and other areas
from the FY 2000 MedPAR file.
2. Computing Large Urban and Other Area Averages
Sections 1886(d)(2)(D) and (d)(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 (d)(9)(C)(i) of the Act, the average
standardized amount per discharge must be determined for hospitals
located in large 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
million. 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 1999 population estimates published by the Bureau of the
Census, 63 areas meet the criteria to be defined as large urban areas
for FY 2002. These areas are identified in Table 4A.
3. Updating the Average Standardized Amounts
Under section 1886(d)(3)(A) of the Act, we update the 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 2002 using the
applicable percentage increases specified in section 1886(b)(3)(B)(i)
of the Act. Section 1886(b)(3)(B)(i)(XVII) of the Act as amended by
section 301 of Public Law 106-554 specifies that the update factor for
the standardized amounts for FY 2002 is equal to the market basket
percentage increase minus 0.55 percentage points for hospitals in all
areas. Section 301 also established that the update factor for FY 2003
is equal to the market basket percentage increase minus 0.55 percentage
points. We are revising Sec. 412.63 to reflect these changes.
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 2002 is 3.3 percent. Thus, for FY 2002, the
update to the average standardized amounts equals 2.75 percent for
hospitals in all areas.
As in the past, we are adjusting the FY 2001 standardized amounts
to remove the effects of the FY 2001 geographic reclassifications and
outlier payments before applying the FY 2002 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 2002.
Although the update factors for FY 2002 are set by law, we are
required by section 1886(e)(3) of the Act to report to the Congress our
initial recommendation of update factors for FY 2002 for both
prospective payment hospitals and hospitals excluded from the
prospective payment system.
We have included our final recommendations on the update factors 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 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 FY 2000
discharge data to simulate payments and compared aggregate payments
using the FY 2001 relative weights and wage index to aggregate payments
using the FY 2002 relative weights and wage index. The same methodology
was used for the FY 2001 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 0.995821. 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 0.997209. These budget neutrality
adjustment factors are applied to the standardized amounts without
removing the effects of the FY 2001 budget neutrality adjustments. For
FY 2001, we used an average of the budget neutrality factor that was in
effect from October 1, 2000 through March 30, 2001 and the budget
neutrality factor that was in effect from April 1, 2001 through
September 30, 2001 (0.997225 and 0.997122, respectively). 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, 2001. (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, effective with
discharges occurring on or after October 1, 1988, certain rural
hospitals are deemed urban. In addition, section 1886(d)(10) of the Act
provides for the reclassification of hospitals based on determinations
by the Medicare
[[Page 39941]]
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 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 FY 2000 discharge data to simulate payments, and
compared total prospective payments (including IME and disproportionate
share hospital (DSH) payments) prior to any reclassifications to total
prospective payments after reclassifications. Based on these
simulations, we are applying an adjustment factor of 0.990675 to ensure
that the effects of reclassification are budget neutral.
The adjustment factor is applied to the standardized amounts after
removing the effects of the FY 2001 budget neutrality adjustment
factor. We note that the proposed FY 2002 adjustment reflected wage
index and standardized amount reclassifications approved by the MGCRB
or the Administrator as of February 28, 2001, and the effects of
section 304 of Public Law 106-554 to extend wage index
reclassifications for 3 years. The effects of any additional
reclassification changes that occurred as a result of appeals and
reviews of the MGCRB decisions for FY 2002 or from a hospital's request
for the withdrawal of a reclassification request for FY 2002 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 2002 outlier thresholds. For FY 2001, the fixed loss cost
outlier threshold published in the August 1, 2000 final rule was equal
to the prospective payment rate for the DRG plus the IME and DSH
payments plus $17,550 ($16,036 for hospitals that have not yet entered
the prospective payment system for capital-related costs). As a result
of the change made by Public Law 106-554 to the update factor for the
operating standardized amounts, this threshold was applicable for
discharges on or after October 1, 2000 and before April 1, 2001. For
discharges occurring on or after April 1, 2001 and before October 1,
2001, the threshold was equal to the prospective payment rate for the
DRG plus the IME and DSH payments plus $16,350 ($14,940 for hospitals
that have not yet entered the prospective payment system for capital-
related costs). The revision to the threshold was discussed in the
interim final rule with comment period published on June 13, 2001 (66
FR 32176). (In the June 13, 2001 interim final rule with comment
period, the fixed loss amount was stated as $16,500. This was an error;
the correct amount is $16,350. This is the amount that has been applied
to discharges since April 1, 2001, in the PRICER software used to
determine payments.) The marginal cost factor for cost outliers (the
percent of costs paid after costs for the case exceed the threshold)
was 80 percent.
For FY 2002, 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 $21,000. The capital prospective payment
system is fully phased in, effective FY 2002. Therefore, we no longer
are establishing a separate threshold for hospitals that have not yet
entered the prospective payment system for capital-related costs. We
proposed to maintain the marginal cost factor for cost outliers at 80
percent.
In this final rule, we are establishing a fixed loss cost outlier
threshold equal to the prospective rate for the DRG plus the IME and
DSH payment plus $21,025. In addition, we are maintaining the marginal
cost factor for cost outliers at 80 percent. To calculate the final FY
2002 outlier thresholds, we simulated payments by applying FY 2002
rates and policies to the March 2001 update of the FY 2000 MedPAR file
and the March 2001 update of the Provider-Specific File.
We apply a cost inflation factor to update costs for the cases used
to simulate payments. For FY 2000, we used a cost inflation factor of
zero percent. For FY 2001, we used a cost inflation factor (or cost
adjustment factor) of 1.8 percent. To set the proposed FY 2002 outlier
thresholds, we used a 2-year cost inflation factor of 5.5 percent (to
inflate FY 2000 charges to FY 2002). We are using a cost inflation
factor of 2.8 percent per year to set the final FY 2002 outlier
thresholds (this equates to a 2-year cost inflation factor of 5.7
percent). This factor reflects our analysis of the best available cost
report data as well as calculations (using the best available data)
indicating that the percentage of actual outlier payments for FY 2000
is higher than we projected before the beginning of FY 2000, and that
the percentage of actual outlier payments for FY 2001 will likely be
higher than we projected before the beginning of FY 2001. The
calculations of ``actual'' outlier payments are discussed further
below.
Comment: Several commenters noted that the proposed threshold was
almost 20 percent higher than the threshold effective for FY 2001. The
commenters believed that we should verify the amount of cost outliers
paid in a year and reconcile accordingly. One commenter also suggested
that we amend our method of calculating the threshold so that the
threshold is set at a level that reflects FY 2001 threshold plus a
reasonable updating factor to account for inflation.
Response: As indicated in the proposed rule, and as explained in
numerous previous Federal Register documents, under the policy we have
maintained since the inception of the hospital inpatient prospective
payment system for operating costs, we do not make retroactive
adjustments to reconcile differences between the percentage of outlier
payments projected before a given fiscal year and the ``actual''
outlier payments for that fiscal year.
In accordance with section 1886(d)(5)(A) of the Act, we set outlier
thresholds for an upcoming fiscal year so that outlier payments for the
fiscal year are projected to equal a specified percentage between 5 and
6 percent of total payments based on DRG prospective payment rates. To
set the thresholds, we simulate payments using the best available data.
We believe that the methodology suggested by the commenter, simply
updating the FY 2001 thresholds to account for inflation,
[[Page 39942]]
would not be appropriate because, among other reasons, the methodology
would not reflect the use of the most recent complete data with respect
to discharges and costs. The difference between the FY 2001 outlier
thresholds and the FY 2002 outlier thresholds arises from differences
reflected in the data used to set the respective thresholds.
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 accordance with section
1886(d)(3)(E), we reduced the FY 2002 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 2002 will result in outlier payments
equal to 5.1 percent of operating DRG payments and 5.8 percent of
capital payments based on the Federal rate.
The proposed outlier adjustment factors applied to the standardized
amounts for FY 2002 were as follows:
------------------------------------------------------------------------
Operating Capital
standardized federal
amounts rate
------------------------------------------------------------------------
National..................................... 0.948910 0.974711
Puerto Rico.................................. 0.942593 0.970336
------------------------------------------------------------------------
Based on simulations of payments using updated data, the final
outlier adjustment factors applied to the standardized amounts for FY
2002 are as follows:
------------------------------------------------------------------------
Operating Capital
standardized federal
amounts rate
------------------------------------------------------------------------
National..................................... 0.948928 0.942440
Puerto Rico.................................. 0.974762 0.970140
------------------------------------------------------------------------
As in the proposed rule, we apply the outlier adjustment factors
after removing the effects of the FY 2001 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. These
statewide average ratios replace the ratios published in the August 1,
2000 final rule (65 FR 47054). Table 8B contains comparable statewide
average capital cost-to-charge ratios. These average ratios will be
used to calculate cost outlier payments for those hospitals for which
the fiscal intermediary computes operating cost-to-charge ratios lower
than 0.1903547 or greater than 1.3148656 and capital cost-to-charge
ratios lower than 0.0119230 or greater than 0.1677417. 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 2002 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 2000 and FY 2001 outlier payments. In the August 1, 2000
final rule (65 FR 47054), we stated that, based on available data, we
estimated that actual FY 2000 outlier payments would be approximately
6.2 percent of actual total DRG payments. This was computed by
simulating payments using the March 2000 update of the FY 1999 bill
data available at the time. That is, the estimate of actual outlier
payments did not reflect actual FY 2000 bills but instead reflected the
application of FY 2000 rates and policies to available FY 1999 bills.
Our current estimate, using available FY 2000 bills, is that actual
outlier payments for FY 2000 were approximately 7.6 percent of actual
total DRG payments. We note that the MedPAR file for FY 2000 discharges
continues to be updated. Thus, the data indicate that, for FY 2000, the
percentage of actual outlier payments relative to actual total payments
is higher than we projected before FY 2000 (and thus exceeds the
percentage by which we reduced the standardized amounts for FY 2000).
In fact, the data indicate that the proportion of actual outlier
payments for FY 2000 exceeds 6.0 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 2000.
We currently estimate that actual outlier payments for FY 2001 will
be approximately 6.2 percent of actual total DRG payments, 1.1
percentage points higher than the 5.1 percent we projected in setting
outlier policies for FY 2001. This estimate is based on simulations
using the March 2001 update of the Provider-Specific File and the March
2001 update of the FY 2000 MedPAR file (discharge data for FY 2000
bills). We used these data to calculate an estimate of the actual
outlier percentage for FY 2001 by applying FY 2001 rates and policies
to available FY 2000 bills.
5. FY 2002 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 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.
Comment: Several commenters were unable to reconcile the
standardized amounts published in the proposed rule for FY 2002 with
the rates which were in effect for FY 2001. These commenters requested
that we clarify, by category, the increases and decreases applied to
the standardized amounts in the proposed rule in order to illustrate
the method under which the rates were established.
Response: The confusion likely arises from the two different rates
that were effective during FY 2001. Prior to the passage of Public Law
106-554, section 1886(b)(3)(B)(i) of the Act set the update to the
standardized amounts for FY 2001 as the market basket percentage
increase minus 1.1 percentage points. Section 301(a) of Public Law 106-
554 revised section 1886(b)(3)(B)(i) of the Act to set the update to
the standardized amounts for FY 2001 equal to the full market basket
percentage increase.
Further, section 301(b) of Public Law 106-554 included a special
provision to implement the full market basket update for purposes of
making payments for FY 2001 only. Under this special provision, for
discharges occurring on or after October 1, 2000 and before April 1,
2001, the update factor (other than for SCHs) is equal to the market
basket percentage increase minus 1.1
[[Page 39943]]
percentage points. For discharges occurring on or after April 1, 2001
and before October 1, 2001, the update factor (other than SCHs) is
equal to the market basket percentage increase plus 1.1 percentage
points.
However, section 547 of Public Law 106-554 makes this special rule
applicable solely to payments in FY 2001 and the payment increases
under section 301(b) in this fiscal year are not to be taken into
account in developing payments for future fiscal years. Consequently,
when we established the rates for FY 2002, we based the calculation on
FY 2001 standardized amounts reflecting the full FY 2001 market basket
percentage increase of 3.4 percent. Since the standardized amounts
calculated using the full market basket were not actually used for
payment during FY 2001, they were not published in either the August 1,
2000 final rule or the June 13, 2001 interim final rule with comment
period.
To arrive at the final FY 2002 standardized amounts, we updated the
standardized amounts through FY 2001 using the full market basket of
3.4 percent (without applying a geographic budget neutrality factor or
outlier factor), then multiplied this amount by: the update factor for
FY 2002; the wage and recalibration budget neutrality factor; the
geographic reclassification budget neutrality factor; and the outlier
factor established for FY 2002. The calculation below details this
reconciliation process using the large urban area standardized amount
as an example. Although the commenters requested a reconciliation of
the proposed rates, the example below reconciles the final FY 2002
rates, as those are the amounts actually in effect for the fiscal year.
To reconcile the rates in the proposed rule, the exact same methodology
applies.
Example of the Calculation of the FY 2002 Final Standardized Amount for
Large Urban Areas
------------------------------------------------------------------------
Labor Nonlabor
------------------------------------------------------------------------
FY 2001 Standardized Amount with Full Market $3,072.51 $1,248.88
Basket Update/No Reclassification, Budget
Neutrality or Outlier Offset.................
Update Factor: (Market Basket Percentage 1.0275 1.0275
Increase minus 0.55 percent).................
FY 2002 Wage Index and DRG reclassification/ 0.995821 0.995821
recalculation budget neutrality factor.......
FY 2002 Reclassification budget neutrality 0.990675 0.990675
factor.......................................
Outlier Factor................................ 0.948928 0.948928
Final Rate for FY 2002 (after multiplying FY $2,955.44 $1,201.30
2001 base rate by above factors).............
------------------------------------------------------------------------
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 that will be used to calculate the
prospective payment rates for hospitals located in the 50 States, the
District of Columbia, and Puerto Rico. This section addresses two types
of adjustments to the standardized amounts that are made in determining
the prospective payment rates as described in this Addendum.
1. Adjustment for Area Wage Levels
Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require
that 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 2002 wage
index. The wage index is set forth in Tables 4A, 4B, 4C, and 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 2002,
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......................... 1.165
County of Kauai.......................... 1.2325
County of Maui........................... 1.2375
County of Kalawao........................ 1.2375
------------------------------------------------------------------------
(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 2002.
These factors have been recalibrated as explained in section II. of the
preamble.
D. Calculation of Prospective Payment Rates for FY 2002
General Formula for Calculation of Prospective Payment Rates for FY
2002
The prospective payment rate for all hospitals located outside of
Puerto Rico, except SCHs and MDHs, equals the Federal rate.
The prospective payment rate for SCHs equals 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, the updated hospital-specific rate based on FY 1987 cost per
discharge, or, if qualified, 50 percent of the updated hospital-
specific rate based on FY 1996 cost per discharge, plus the greater of
50 percent of the updated FY 1982 or FY 1987 hospital-specific rate or
50 percent of the Federal rate. Section 213 of Public Law 106-554
amended section 1886(b)(3) of the Act to allow all SCHs to rebase their
hospital-specific rate based on their FY 1996 cost per discharge.
The prospective payment rate for MDHs equals 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.
The prospective payment rate for Puerto Rico equals 50 percent of
the
[[Page 39944]]
Puerto Rico rate plus 50 percent of a discharge-weighted average of the
Federal large urban standardized amount and the Federal other
standardized amount.
1. Federal Rate
For discharges occurring on or after October 1, 2001 and before
October 1, 2002, except for SCHs, MDHs, and hospitals in Puerto Rico,
the hospital's payment is based exclusively on the Federal national
rate. The payment amount is determined as follows:
Step 1--Select the appropriate national standardized amount
considering the type of hospital and designation of the hospital as
large urban or other (see Table 1A in section VI. of this Addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the applicable wage index for the geographic area in which
the hospital is located (see Tables 4A, 4B, and 4C of section VI. of
this Addendum).
Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-
related portion of the standardized amount by the appropriate cost-of-
living adjustment factor.
Step 4--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount (adjusted, if appropriate, under Step 3).
Step 5--Multiply the final amount from Step 4 by the relative
weight corresponding to the appropriate DRG (see Table 5 of section VI.
of this Addendum).
2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)
Section 1886(b)(3)(C) of the Act provides that SCHs 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, the updated hospital-specific rate based on
FY 1987 cost per discharge, or, if qualified, 50 percent of the updated
hospital-specific rate based on FY 1996 cost per discharge, plus the
greater of 50 percent of the updated FY 1982 or FY 1987 hospital-
specific rate or 50 percent of the Federal DRG payment rate.
Section 1886(d)(5)(G) of the Act provides that MDHs 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 either the FY 1982 cost per discharge, the FY 1987
cost per discharge or, for qualifying SCHs, the FY 1996 cost per
discharge. For a more detailed discussion of the calculation of the
hospital-specific rates, 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); the September 4, 1990 final rule (55 FR 35994);
and the August 1, 2000 final rule (65 FR 47082).
a. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates
for FY 2002
We are increasing the hospital-specific rates by 2.75 percent (the
hospital market basket percentage increase minus 0.55 percentage
points) for SCHs and MDHs for FY 2002. Section 1886(b)(3)(C)(iv) of the
Act provides that the update factor applicable to the hospital-specific
rates for SCHs equal the update factor provided under section
1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2002, is the market
basket rate of increase minus 0.55 percentage points. Section
1886(b)(3)(D) of the Act provides that the update factor applicable to
the hospital-specific rates for MDHs equals the update factor provided
under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2002, is the
market basket rate of increase minus 0.55 percentage points.
b. Calculation of Hospital-Specific Rate
For SCHs, the applicable FY 2002 hospital-specific rate is based on
the following: the hospital-specific rate calculated using the greater
of the FY 1982 or FY 1987 costs, increased by the applicable update
factor; or, if the hospital-specific rate based on cost per case in FY
1996 is greater than the hospital-specific rate using either the FY
1982 or the FY 1987 costs, the greater of 50 percent of the hospital-
specific rate based on the FY 1982 or FY 1987 costs, increased by the
applicable update factor, or 50 percent of the Federal rate plus 50
percent of its rebased FY 1996 hospital-specific rate updated through
FY 2002. For MDHs, the applicable FY 2002 hospital-specific rate is
calculated by increasing the hospital's hospital-specific rate for the
preceding fiscal year by the applicable update factor, which is the
same as the update for all prospective payment hospitals. In addition,
for both SCHs and MDHs, the hospital-specific rate is adjusted by the
budget neutrality adjustment factor (that is, by 0.995821) as discussed
in section II.A.4.a. of this Addendum. The resulting rate is used in
determining the payment rate an SCH or MDH is paid for its discharges
beginning on or after October 1, 2001.
3. General Formula for Calculation of Prospective Payment Rates for
Hospitals Located in Puerto Rico Beginning On or After October 1, 2001
and Before October 1, 2002
a. Puerto Rico Rate
The Puerto Rico prospective payment rate is determined as follows:
Step 1--Select the appropriate adjusted average standardized amount
considering the large urban or other designation of the hospital (see
Table 1C of section VI. of the Addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the appropriate Puerto Rico-specific wage index (see Table 4F
of section VI. of the Addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount.
Step 4--Multiply the result in Step 3 by 50 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5 of section VI. of the Addendum).
b. National Rate
The national prospective payment rate is determined as follows:
Step 1--Multiply the labor-related portion of the national average
standardized amount (see Table 1C of section VI. of the Addendum) by
the appropriate national wage index (see Tables 4A and 4B of section
VI. of the Addendum).
Step 2--Add the amount from Step 1 and the nonlabor-related portion
of the national average standardized amount.
Step 3--Multiply the result in Step 2 by 50 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5 of section VI. of the Addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico.
III. Changes to the Prospective Payment Rates for Inpatient
Operating Costs for FY 2001 (Section 301 of Public Law 106-554 and
42 CFR 412.63(s))
In the June 13, 2001 interim final rule with comment period, we
implemented section 301(a) of Public Law 106-554 as it applied to FY
2001. Section 301(a) amended section 1886(b)(3)(B)(i) of the Act by
changing the percentage increase for the hospital inpatient payment
rates
[[Page 39945]]
for FYs 2001, 2002, and 2003. Previously, section 1886(b)(3)(B)(i) (as
amended by section 406 of Public Law 106-113) established the update
factor to the payment rates for inpatient prospective payment system
hospitals (other than SCHs, who received the full market basket update
effective October 1, 2000) as the market basket percentage increase
minus 1.1 percent for FYs 2001 and 2002; the update factor for FY 2003
and subsequent fiscal years was established as the full market basket
percentage increase. Section 301(a) of Public Law 106-554 amended
section 1886(b)(3)(B)(i) of the Act and changed the update factor for
FY 2001 to the full market basket percentage increase. (Section 301(a)
also revised the update factors that apply to FYs 2002 and 2003, as
discussed in section II. of this Addendum.) Prior to enactment of
Public Law 106-554, the update factor for FY 2002 was the market basket
percentage increase minus 1.1 percentage points and the update factor
for FY 2003 was the full market basket percentage increase. Section
301(a) of Public Law 106-554 amended section 1886(b)(3)(B)(i) of the
Act to revise the update factor for FYs 2002 and 2003 to be the market
basket percentage increase minus 0.55 percentage points.
Further, section 301(b) of Public Law 106-554 provided a special
rule to implement the full market basket update to inpatient hospital
prospective payment rates for FY 2001. Under this special rule, for
discharges occurring on or after October 1, 2000 and before April 1,
2001, the update factor for inpatient prospective payment system
hospitals (other than SCHs) is equal to the market basket percentage
increase minus 1.1 percentage points. For discharges occurring on or
after April 1, 2001 and before October 1, 2001, the update factor for
the payment rates for inpatient prospective payment system hospitals
(other than SCHs) is equal to the market basket percentage increase
plus 1.1 percentage points. Section 547 of Public Law 106-554 makes
this special rule applicable solely to payments in FY 2001 and the
payment increases resulting for FY 2001 are not taken into account in
developing payments for future fiscal years.
As directed by the special rule in section 301(b) of Public Law
106-554, any discharges occurring on or after October 1, 2000, and
before April 1, 2001, are paid in accordance with the standardized
amounts set forth in the FY 2001 hospital inpatient prospective payment
system final rule published in the August 1, 2000 Federal Register (65
FR 47126). These rates were calculated using the market basket
percentage increase of 3.4 percent minus 1.1 percentage points, for a
2.3 percent increase (see 65 FR 47112), as directed by section
1886(b)(3)(B)(i) of the Act prior to the passage of Public Law 106-554.
To implement the special rule under section 301(b) of Public Law
106-554, in the June 13 interim final rule with comment period, we
recomputed the standardized amounts effective for discharges occurring
on or after April 1, 2001. That is, we replaced the update factor of
2.3 percent applied to the standardized amounts in the August 1, 2000
final rule, with the update factor of 4.5 percent (the market basket
percentage increase plus 1.1 percentage points, or 3.4 plus 1.1
percentage points).
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------
Labor- Nonlabor- Labor- Nonlabor-
related related related related
----------------------------------------------------------------------------------------------------------------
National.................................................... $2,925.82 $1,189.26 $2,879.51 $1,170.43
National PR................................................. 2,900.64 1,179.02 2,900.64 1,179.02
Puerto Rico................................................. 1,402.79 564.66 1,380.58 555.72
SCHs........................................................ 2,895.02 1,176.74 2,849.20 1,158.11
----------------------------------------------------------------------------------------------------------------
A. Budget Neutrality
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 projected to be the same as those that would
have been made without such adjustments. 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 projected to be the same as those
that would have been made without the change in the wage index.
Finally, under section 1886(d)(8)(D) of the Act, the Secretary is
required to adjust the standardized amounts so as to ensure that final
aggregate payments under the prospective payment system are projected
to equal the aggregate prospective payments that would have been made
absent the geographic reclassification provisions of sections
1886(d)(8)(B) and (C) and 1886(d)(10) of the Act.
The distributive effects on hospital payments of the IME and DSH
changes also included in Public Law 106-554 required us to recalculate
the budget neutrality factors that are required by section
1886(d)(8)(D) of the Act.
As we stated in the June 13, 2001 interim final rule with comment
period, the budget neutrality factors that were used to establish the
standardized amounts effective for discharges occurring on or after
October 1, 2000 were: 0.997225 for the DRG reclassification and
recalibration and updated wage index (65 FR 47112); and 0.993187 for
geographic reclassification (65 FR 47113). Using the same methodology
that was used to calculate the budget neutrality factors in the August
1, 2000 final rule, the corresponding budget neutrality factors for the
standardized amounts effective for discharges occurring on or after
April 1, 2001 and before October 1, 2001 are 0.997122 and 0.993279. The
FY 2001 budget neutrality factor for Puerto Rico did not change.
Therefore, the budget neutrality factor for Puerto Rico as published in
the August 1, 2000 Federal Register (65 FR 47112) remained in effect
for discharges occurring on or after April 1, 2001 and before October
1, 2001.
B. Outliers
In accordance with section 1886(d)(3)(B) of the Act, which directs
the Secretary to adjust the national standardized amounts to account
for the estimated proportion of total payments made to outlier cases,
the fixed-loss outlier threshold was also revised as a result of the
change made by Public Law 106-554 to the update factor for the
operating standardized amounts. For discharges occurring on or after
April 1, 2001 and before October 1, 2001, we established a fixed-loss
cost outlier threshold equal to the prospective payment rate for the
DRG, plus IME and
[[Page 39946]]
DSH payments, plus $16,350 ($14,940 for hospitals that have not yet
entered the prospective payment system for capital-related costs). (In
the June 13, 2001 interim final rule with comment period, the fixed
loss amount was stated as $16,500. This was an error. The correct
amount is $16,350. This is the amount that has been applied to
discharges since April 1, 2001, in the PRICER software used to
determine payments.) In determining the outlier threshold, we used the
same methodology employed to determine the outlier threshold for FY
2001 (65 FR 47113 through 47114). Outlier payments for discharges
occurring on or after October 1, 2000 and before April 1, 2001, will be
determined in accordance with the standardized amounts and outlier
thresholds set forth in the FY 2001 final rule published in the August
1, 2000 Federal Register (65 FR 47113).
Although the market basket percentage used to update SCHs was not
revised by Public Law 106-554, the standardized amounts applied to
these hospitals for discharges occurring on or after April 1, 2001 and
before October 1, 2001 also increase slightly. This increase in SCH
rates is due to the budget neutrality factors effective for this
portion of the fiscal year.
For discharges occurring on or after April 1, 2001 and before
October 1, 2001, the outlier adjustment factors are as follows:
------------------------------------------------------------------------
Operating Capital
standardized federal
amounts rate
------------------------------------------------------------------------
National..................................... 0.948929 0.937854
Puerto Rico.................................. 0.973671 0.967355
------------------------------------------------------------------------
III. Changes to Payment Rates for Inpatient Capital-Related Costs
for FY 2002
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 capital Federal rate rate and
the hospital-specific rates for FY 2002. The rates, which will be
effective for discharges occurring on or after October 1, 2001. As we
stated in section V. of the preamble of this final rule, we are no
longer determining an update to the capital hospital-specific rate,
since FY 2001 is the last year of the 10-year transition period, and
beginning in FY 2002 all hospitals (except ``new'' hospitals under
Sec. 412.324(b)) will be paid based on 100 percent of the capital
Federal rate.
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 (regular and special)
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 Public Law
105-33, 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.
To determine the appropriate budget neutrality adjustment factor
and the regular exceptions payment adjustment, 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 regular 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, 1997, as a result of section 4406 of Public Law 105-33,
operating payments to hospitals in Puerto Rico are based on a blend of
50 percent of the applicable standardized amount specific to Puerto
Rico hospitals and 50 percent of the applicable national average
standardized amount. In conjunction with this change to the operating
blend percentage, effective with discharges on or after October 1,
1997, we compute capital payments to hospitals in Puerto Rico based on
a blend of 50 percent of the Puerto Rico rate and 50 percent of the
Federal rate.
Section 412.374 provides for the use of this blended payment system
for payments to Puerto Rico hospitals under the prospective payment
system for inpatient capital-related costs. Accordingly, for capital-
related costs, we compute a separate payment rate specific to Puerto
Rico hospitals using the same methodology used to compute the national
Federal rate for capital.
A. Determination of Federal Inpatient Capital-Related Prospective
Payment Rate Update
In the August 1, 2000 final rule (65 FR 47122), we established a
Federal rate of $382.03 for FY 2001. In the June 13, 2001 interim final
rule with comment, as a result of implementing section 301(b) of Public
Law 106-554, we established a Federal rate of $380.85 for discharges
occurring on or after April 1, 2001 and before October 1, 2001 (66 FR
32180). (See section V.E. of the preamble and section III.A.5 of this
Addendum for a fuller discussion of the provisions of section 301(b) of
Public Law 106-554.) In accordance with section 547 of Public Law 106-
554, the special payment increases provided by Public Law 106-554
effective between
[[Page 39947]]
April and October 2001 do not apply for discharges occurring after FY
2001 and are not taken into account in determining the payment rates in
subsequent years. Thus, the adjustments and rates published in the
August 1, 2000 final rule were used in determining the FY 2002 capital
rates. As a result of the changes to the factors used to establish the
Federal rate in this addendum, the FY 2002 Federal rate is $390.74.
In the discussion that follows, we explain the factors that were
used to determine the FY 2002 Federal rate. In particular, we explain
why the FY 2002 Federal rate has increased 2.28 percent compared to the
FY 2001 Federal rate (published in the August 1, 2000 final rule (65 FR
47122)). We also estimate aggregate capital payments will increase by
4.27 percent during this same period. This increase is primarily due to
the increase in the number of hospital admissions and the increase in
case-mix. This increase in capital payments is slightly less than last
year (5.48 percent) because with the end of the transition period the
remaining hold harmless hospitals receiving ``cost-based'' payments
will begin being paid based on 100 percent of the Federal rate.
Total payments to hospitals under the prospective payment system
are relatively unaffected by changes in the capital prospective
payments. Since capital payments constitute about 10 percent of
hospital payments, a 1 percent change in the capital Federal rate
yields only about 0.1 percent change in actual payments to hospitals.
Aggregate payments under the capital prospective payment system are
estimated to increase in FY 2002 compared to FY 2001.
1. Standard Federal Rate Update
Under Sec. 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 for FY 2002 under that
framework of 1.1 percent, based on data available at that time. Under
the update framework, the final update factor for FY 2002 is 1.3
percent. This update factor is based on a projected 0.7 percent
increase in the CIPI, a 0.3 percent adjustment for intensity, a 0.0
percent adjustment for case-mix, a 0.0 percent adjustment for the FY
2000 DRG reclassification and recalibration, and a forecast error
correction of 0.3 percent. We explain the basis for the FY 2002 CIPI
projection in section II.C. of this Addendum. Below we describe the
policy adjustments that have been applied.
The case-mix index is the measure of the average DRG weight for
cases paid under the prospective payment system. Because the DRG weight
determines the prospective payment for each case, any percentage
increase in the case-mix index corresponds to an equal percentage
increase in hospital payments.
The case-mix index can change for any of several reasons:
The average resource use of Medicare patients changes
(``real'' case-mix change);
Changes in hospital coding of patient records result in
higher weight DRG assignments (``coding effects''); and
The annual DRG reclassification and recalibration changes
may not be budget neutral (``reclassification effect'').
We define real case-mix change as actual changes in the mix (and
resource requirements) of Medicare patients as opposed to changes in
coding behavior that result in assignment of cases to higher weighted
DRGs but do not reflect higher resource requirements. In the update
framework for the prospective payment system for operating costs, we
adjust the update upwards to allow for real case-mix change, but remove
the effects of coding changes on the case-mix index. We also remove the
effect on total payments of prior changes to the DRG classifications
and relative weights, in order to retain budget neutrality for all
case-mix index-related changes other than patient severity. (For
example, we adjusted for the effects of the FY 2000 DRG
reclassification and recalibration as part of our FY 2002 update
recommendation.) We have adopted this case-mix index adjustment in the
capital update framework as well.
For FY 2002, we are projecting a 1.0 percent increase in the case-
mix index. We estimate that real case-mix increase will equal 1.0
percent in FY 2002. Therefore, the net adjustment for case-mix change
in FY 2002 is 0.0 percentage points.
We estimate that FY 2000 DRG reclassification and recalibration
will result in a 0.0 percent change in the case-mix when compared with
the case-mix index that would have resulted if we had not made the
reclassification and recalibration changes to the DRGs. Therefore, we
are making a 0.0 percent adjustment for DRG reclassification and
recalibration in the update recommendation for FY 2002.
The capital update framework contains an adjustment for forecast
error. The input price index forecast is based on historical trends and
relationships ascertainable at the time the update factor is
established for the upcoming year. In any given year, there may be
unanticipated price fluctuations that may result in differences between
the actual increase in prices and the forecast used in calculating the
update factors. In setting a prospective payment rate under the
framework, we make an adjustment for forecast error only if our
estimate of the change in the capital input price index for any year is
off by 0.25 percentage points or more. There is a 2-year lag between
the forecast and the measurement of the forecast error. A forecast
error of 0.3 percentage points was calculated for the FY 2000 update.
That is, current historical data indicate that the forecasted FY 2000
CIPI used in calculating the FY 2000 update factor (0.6 percent)
understatethe actual realized price increases (0.9 percent) by 0.3
percentage points. This under-prediction was due to prices from
municipal bond yields declining slower than expected. Therefore, we are
making a 0.0 3 percent adjustment for forecast error in the update for
FY 2002.
Under the capital prospective payment system framework, we also
make an adjustment for changes in intensity. We calculate this
adjustment using the same methodology and data as in the framework for
the operating prospective payment system. The intensity factor for the
operating update framework reflects how hospital services are utilized
to produce the final product, that is, the discharge. This component
accounts for changes in the use of quality-enhancing services, changes
in within-DRG severity, and expected modification of practice patterns
to remove cost-ineffective services.
We calculate case-mix constant intensity as the change in total
charges per admission, adjusted for price level changes (the CPI for
hospital and related services), and changes in real case-mix. The use
of total charges in the calculation of the proposed intensity factor
makes it a total intensity factor, that is, charges for capital
services are already built into the calculation of the factor.
Therefore, we have incorporated the intensity adjustment from the
operating update framework into the capital update framework. Without
reliable estimates of the proportions of the overall annual intensity
increases that are due, respectively, to ineffective practice patterns
and to the combination
[[Page 39948]]
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 2002, we have developed a Medicare-specific intensity
measure based on a 5-year average, using FY 1996 through 2000 data. In
determining case-mix constant intensity, we found that observed case-
mix increase was 1.6 percent in FY 1996, 0.3 percent in FY 1997, -0.4
percent in FY 1998, and -0.3 in FY 1999, and -0.7 percent in FY 2000.
Since we found an increase in case-mix of 1.6 for FY 1996, which was
outside of the range of 1.0 to 1.4 percent, we estimate that real case-
mix increase was 1.0 to 1.4 percent for that year. The estimate of 1.0
to 1.4 percent 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 1.4 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 1996 through FY 2000. Based on this analysis,
we believe that all of the observed case-mix increase for FY 1997, FY
1998, and FY 1999, and FY 2000 is real. The increases for FY 1996 was
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 for
hospital and related services), and changes in real case-mix. Based
upon an upper limit of 1.0 percent real case-mix increase, we estimate
that case-mix constant intensity increased by an average 0.3 percent
during FYs 1996 through 2000, for a cumulative increase of 1.4 percent,
given estimates of real case-mix of -1.0 percent for FY 1996, 0.3
percent for FY 1997, -0.4 for FY 1998, and -0.3 for FY 1999, and -0.7
percent for FY 2000. Based upon an upper limit of 1.4 percent real
case-mix increase, we estimate that case-mix constant intensity
declined increase by an average 0.2 percent during FYs 1996 through
2000, for a cumulative increase of 1.2 percent, given that real case-
mix increase was 1.4 percent for FY 1996, 0.3 percent for FY 1997, -0.4
for FY 1998, -0.3 for FY 1999, and -0.7 percent for FY 2000. Since we
estimate that intensity has increased during that period, we are
recommending a 0.3 percent intensity adjustment for FY 2002.
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. 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 capital-related outlier payments to total inpatient
capital-related prospective payment system payments. The outlier
thresholds are set so that operating outlier payments are projected to
be 5.1 percent of total operating DRG payments.
In the August 1, 2000 final rule, we estimated that outlier
payments for capital in FY 2001 would equal 5.91 percent of inpatient
capital-related payments based on the Federal rate (65 FR 47121).
Accordingly, we applied an outlier adjustment factor of 0.9409 to the
Federal rate. Based on the thresholds as set forth in section II.A.4.c.
of this Addendum, we estimate that outlier payments for capital will
equal 5.76 percent of inpatient capital-related payments based on the
Federal rate in FY 2002. Therefore, we are establishing an outlier
adjustment factor of 0.9424 to the Federal rate. Thus, the projected
percentage of capital outlier payments to total capital standard
payments for FY 2002 is lower than the percentage for FY 2001.
The outlier reduction factors are not built permanently into the
rates; that is, they are not applied cumulatively in determining the
Federal rate. As explained previously, in accordance with section 547
of Public Law 106-554, the FY 2002 rates are based on the FY 2001
adjustments and rates published in the August 1, 2000 final rule (65 FR
47122). Therefore, the net change in the outlier adjustment to the
Federal rate for FY 2002 is 1.0016 (0.9424/0.9409). The outlier
adjustment increases the FY 2002 Federal rate by 0.16 percent compared
with the FY 2001 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 geographic
adjustment factor (GAF) are projected to equal aggregate payments that
would have been made on the basis of the Federal rate without such
changes. We use the actuarial model, described in Appendix B of this
final rule, to estimate the aggregate payments that would have been
made on the basis of the Federal rate without changes in the DRG
classifications and weights and in the GAF. We also use the model to
estimate aggregate payments that would be made on the basis of the
Federal rate as a result of those changes. We then use these figures to
compute the adjustment required to maintain budget neutrality for
changes in DRG weights and in the GAF.
For FY 2001, we calculated a GAF/DRG budget neutrality factor of
0.9979. In the proposed rule for FY 2002, we proposed a GAF/DRG budget
neutrality factor of 0.9913. In this final rule, based on calculations
using updated data, we are applying a factor of 0.9934. 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 or less than they would have been in the absence of the
annual DRG reclassification and recalibration and changes in the GAF.
As explained previously, in accordance with section 547 of Public Law
106-554, the FY 2002 adjustments and rates are based on the FY 2001
adjustment and rates published in the August 1, 2000 final rule (65 FR
47122). The incremental change in the adjustment from FY 2001 to FY
2002 is 0.9934. The cumulative change in the rate due to this
adjustment is 0.9927 (the product of the incremental factors for FY
1993, FY 1994, FY 1995, FY 1996, FY 1997, FY 1998, FY 1999, FY 2000, FY
2001 and the incremental factor for FY 2002:0.9980 x 1.0053 x 0.9998
x 0.9994 x 0.9987 x 0.9989 x 1.0028 x 0.9985 x 0.9979 x 0.9934
=0.9927).
This factor accounts for DRG reclassifications and recalibration
and for changes in the GAF. It also
[[Page 39949]]
incorporates the effects on the GAF of FY 2002 geographic
reclassification decisions made by the MGCRB compared to FY 2001
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 capital payments payments under
the hospital-specific rate and Federal rate. We use the model
originally developed for determining the budget neutrality adjustment
factor to determine the regular exceptions payment adjustment factor.
We describe that model in Appendix B to this final rule. An adjustment
for regular exceptions is necessary for determining the FY 2002 rates
because we will continue to pay regular exceptions for cost reporting
periods beginning before October 1, 2001 but ending in FY 2002, in
accordance with Sec. 412.312(c)(3). In FY 2003 and later, no payments
will be made under the regular exceptions provision, and then we will
only compute a budget neutrality adjustment under Sec. 412.348(d) for
special exceptions. We describe the methodology to determine the
special exceptions adjustment in section V.D. of this final rule. For
FY 2002, the exceptions adjustment is a combination of the adjustment
that would be made under the regular exceptions provision and under the
special exceptions provision under Sec. 412.348(g).
For FY 2001, we estimated that exceptions payments would equal 2.15
percent of aggregate payments based on the Federal rate. Therefore, we
applied an exceptions reduction factor of 0.9785 (1--;0.0215) in
determining the Federal rate. In the May 4, 2001 proposed rule, we
estimated that regular exceptions payments for FY 2002 would equal 0.63
percent of aggregate payments based on the Federal rate, we estimated
that special exceptions payments for FY 2002 would equal 0.12 percent
of aggregate payments based on the Federal rate. Therefore, we
estimated that total exceptions payments for FY 2002 would equal 0.75
percent (0.63 + 0.12 = 0.75) of aggregate payments based on the Federal
rate, and we proposed an exceptions payment reduction factor of 0.9925
(1--;0.0075) to the Federal rate for FY 2002. The proposed exceptions
reduction factor for FY 2002 was 1.43 percent higher than the factor
for FY 2001 published in the August 1, 2000 final rule.
For this final rule, based on updated data, we estimate that
regular exceptions payments for FY 2002 will equal 0.59 percent of
aggregate payments based on the Federal rate, and we estimate that
special exceptions payments for FY 2002 will equal 0.12 percent of
aggregate payments based on the Federal rate. We estimate that total
exceptions payments for FY 2002 will be 0.71 percent (0.59 + 0.12 =
0.71). Thus, the FY 2002 exceptions payment reduction factor is 0.9929
(1--0.0071). The exceptions reduction factor for FY 2002 is 1.47
percent higher than the factor for FY 2001 published in the August 1,
2000 final rule. This increase is primarily due to the expiration of
the regular exceptions provision and the narrowly defined nature of the
special exceptions policy.
The exceptions reduction factors are not built permanently into the
rates; that is, the factors are not applied cumulatively in determining
the Federal rate. As explained previously, in accordance with section
547 of Public Law 106-554, the FY 2002 adjustments and rates are based
on the FY 2001 adjustments and rates published in the August 1, 2000
final rule (65 FR 47122). Therefore, the net adjustment to the FY 2002
Federal rate is 0.9929/0.9785, or 1.0147.
5. Standard Capital Federal Rate for FY 2002
For FY 2001, the capital Federal rate was $382.03 for discharges
occurring between October 1, 2000 and April 1, 2001. As a result of
implementing section 301(b) of Public Law 106-554, for discharges
occurring from April to October 2001, the capital Federal rate was
$380.85. However, as explained previously, in accordance with section
547 of Public Law 106-554, the FY 2002 adjustments and rates are based
on the FY 2001 adjustments and rates published in the August 1, 2000
final rule (65 FR 47122). As a result of changes we are making to the
factors used to establish the Federal rate, in this final rule we are
establishing the capital Federal rate for FY 2002 of $390.74. The
Federal rate for FY 2002 was calculated as follows:
The FY 2002 update factor is 1.0130; that is, the update
is 1.30 percent.
The FY 2002 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 0.9934.
The FY 2002 outlier adjustment factor is 0.94214.
The FY 2002 (regular and special) exceptions payments
adjustment factor is 0.9929.
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 2002 affected the computation of the FY 2002 Federal
rate in comparison to the FY 2001 Federal rate. The FY 2002 update
factor has the effect of increasing the Federal rate by 1.30 percent
compared to the FY 2001 rate published in the August 1, 2000 final
rule, while the geographic and DRG budget neutrality factor has the
effect of decreasing the Federal rate by 0.66 percent. The FY 2002
outlier adjustment factor has the effect of increasing the Federal rate
by 0.16 percent compared to the FY 2001 rate published in the August 1,
2000 final rule. The FY 2002 (regular and special) exceptions reduction
factor has the effect of increasing the Federal rate by 1.47 percent
compared to the exceptions reduction for FY 2001. The combined effect
of all the proposed changes is to increase the Federal rate by 2.28
percent compared to the Federal rate for FY 2001.
Comparison of Factors and Adjustments: FY 2001 Federal Rate and FY 2002 Federal Rate
----------------------------------------------------------------------------------------------------------------
Percent
FY 2001 FY 2002 Change change
----------------------------------------------------------------------------------------------------------------
Update factor\1\............................................ 1.0090 1.0130 1.0130 1.30
GAF/DRG Adjustment Factor\1\................................ 0.9979 0.9934 0.9934 -0.66
Outlier Adjustment Factor\2\................................ 0.9409 0.9424 1.0016 0.16
[[Page 39950]]
Exceptions Adjustment Factor\2\............................. 0.9785 0.9929 1.0147 1.47
Federal Rate................................................ $382.03 $390.74 1.0228 2.28
----------------------------------------------------------------------------------------------------------------
\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 2000 to FY 2001 resulting from the application of the 0.9934 GAF/DRG
budget neutrality factor for FY 2001 is 0.9934.
\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 2001 outlier reduction factor is 0.9424/0.9409, or 1.0016.
As stated previously in this section, the FY 2002 Federal rate has
increased 2.28 percent compared to the FY 2001 capital Federal rate as
a result of the FY 2002 factors and adjustments applied to the capital
Federal rate. Specifically, the capital update factor increased the
capital Federal rate 1.30 percent over FY 2001. The exceptions
reduction factor increased 1.47 percent from 0.9875 to 0.9929 for FY
2002, which results in an increase to the capital Federal rate for FY
2002. Also, the outlier adjustment factor increased 0.16 percent from
0.9409 for FY 2001 to 0.9424 for FY 2002, which results in an increase
to the capital Federal rate in FY 2002 compared to FY 2001. The GAF/DRG
adjustment factor decreased 0.66 percent from 0.9979 for FY 2001 to
0.9934 for FY 2002, which results in a decrease the capital Federal
rate for FY 2002 compared to FY 2001. The effect of all these changes
is a 2.28 percent increase in the FY 2002 capital Federal rate compared
to FY 2001.
We are also providing a chart that shows how the final FY 2002
capital Federal rate differs from the proposed FY 2002 capital Federal
rate.
Comparison of Factors and Adjustments: FY 2002 Proposed Federal Rate and FY 2002 Final Federal Rate
----------------------------------------------------------------------------------------------------------------
Proposed FY Final FY Percent
2002 2002 Change change
----------------------------------------------------------------------------------------------------------------
Update factor............................................... 1.0110 1.0130 1.0020 0.20
GAF/DRG Adjustment Factor................................... 0.9913 0.9934 1.0021 0.21
Outlier Adjustment Factor................................... 0.9426 0.9424 0.9998 -0.02
Exceptions Adjustment Factor................................ 0.9925 0.9929 1.0004 0.04
Federal Rate................................................ $389.09 $390.74 1.0042 0.42
----------------------------------------------------------------------------------------------------------------
6. Special Rate for Puerto Rico Hospitals
As explained at the beginning of section II.D. of this Addendum,
hospitals in Puerto Rico are paid based on 50 percent of the Puerto
Rico rate and 50 percent of the Federal rate. The Puerto Rico rate is
derived from the costs of Puerto Rico hospitals only, while the Federal
rate is derived from the costs of all acute care hospitals
participating in the prospective payment system (including Puerto
Rico). To adjust hospitals' capital payments for geographic variations
in capital costs, we apply a 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.
Because we implemented a separate GAF for Puerto Rico in FY 1998,
we also apply separate budget neutrality adjustments for the national
GAF and for the Puerto Rico GAF. However, we apply the same budget
neutrality factor for DRG reclassifications and recalibration
nationally and for Puerto Rico. The Puerto Rico GAF budget neutrality
factor is 0.9899, while the DRG adjustment is 0.9967, for a combined
cumulative adjustment of 0.9866.
In computing the payment for a particular Puerto Rico hospital, the
Puerto Rico portion of the rate (50 percent) is multiplied by the
Puerto Rico-specific GAF for the MSA in which the hospital is located,
and the national portion of the rate (50 percent) is multiplied by the
national GAF for the MSA in which the hospital is located (which is
computed from national data for all hospitals in the United States and
Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to
the Puerto Rico rate as a result of Public Law 105-33.
For FY 2001, before application of the GAF, the special rate for
Puerto Rico hospitals was $185.06. As explained previously, in
accordance with section 547 of Public Law 106-554, the FY 2002
adjustments and rates are based on the FY 2001 rates published in the
August 1, 2000 final rule. With the changes we proposed to the factors
used to determine the rate, the proposed FY 2002 special rate for
Puerto Rico was $188.67. In this final rule, based on the final
factors, the FY 2002 capital rate for Puerto Rico is $187.73.
7. Changes in the Capital Prospective Payment System Rates for FY 2001
In the June 13, 2001 interim final rule with comment period, we
implemented section 301(b) of Public Law 106-554 (66 FR 32180).
Section 301(b) of Public Law 106-554 provided a special rule to
implement the full market basket update to inpatient hospital operating
prospective payment rates for FY 2001. Under this special rule, for
discharges occurring on or after October 1, 2000 and before April 1,
2001, the update factor for inpatient prospective payment system
hospitals (other than SCHs) is equal to the market basket percentage
increase minus 1.1 percentage points. For discharges occurring on or
after April 1, 2001 and before October 1, 2001, the update factor for
the payment rates for inpatient prospective payment system hospitals
(other than SCHs) is equal to the market basket percentage increase
plus 1.1 percentage points. Section 547 of Public Law 106-554 makes
this special rule applicable solely to payments in FY 2001, and the
payment increases resulting for FY 2001 are not taken into
[[Page 39951]]
account in developing payments for future fiscal years.
As directed by the special rule in section 301(b) of Public Law
106-554, any discharges occurring on or after October 1, 2000, and
before April 1, 2001, will be paid in accordance with the standardized
amounts set forth in the FY 2001 hospital inpatient prospective payment
system final rule published in the August 1, 2000 Federal Register (65
FR 47126). These rates were calculated using the market basket
percentage increase of 3.4 percent minus 1.1 percentage points, for a
2.3 percent increase (see 65 FR 47112), as directed by section
1886(b)(3)(B)(i) of the Act, prior to the passage of Public Law 106-
554.
As stated in the June 13, 2001 interim final rule with comment
period, to implement the special rule under section 301(b) of Public
Law 106-554, we recomputed the standardized amounts effective for
discharges occurring on or after April 1, 2001. That is, we replaced
the update factor of 2.3 percent applied to the standardized amounts in
the August 1, 2000 final rule, with the update factor of 4.5 percent
(the market basket percentage increase plus 1.1 percentage point, or
3.4 plus 1.1 percentage points).
As published in the June 13, 2001 interim final rule with comment
period (66 FR 32180), the revised capital Federal rate for discharges
occurring on or after April 1 2001, and before October 1, 2001, are
shown in the table below.
Final FY 2001 Capital Rates
[Effective April 1, 2001 to October 1, 2001]
------------------------------------------------------------------------
------------------------------------------------------------------------
National Rate................................................ $380.85
Puerto Rico Rate............................................. $184.61
------------------------------------------------------------------------
Section 1886(d)(3)(B) of the Act directs the Secretary to adjust
the inpatient operating national standardized amounts to account for
the estimated proportion of operating DRG payments made to payments in
outlier cases. Accordingly, as a result of this change to the update to
the operating standardized amounts for discharges occurring on or after
April 1, 2001, and before October 1, 2001, we revised the fixed-loss
outlier thresholds. The regulations at Sec. 412.312(c) establish a
unified outlier methodology for inpatient operating and inpatient
capital-related costs, which utilizes a single set of thresholds to
identify outlier cases for both inpatient operating and inpatient
capital prospective payment system payments. Because operating DRG
payments increased as a result of section 301 of Public Law 106-554, we
decreased the fixed-loss threshold. The decrease in the outlier
threshold also results in an increase in the estimated outlier payments
for capital from 5.91 percent to 6.21 percent. Thus, the capital
national outlier adjustment factor was revised from 0.9409 (as
specified in the August 1, 2000 final rule (65 FR 47121)) to 0.9379 (as
specified in the June 13, 2001 interim final rule with comment period).
As stated earlier, the basic methodology for determining the
capital Federal rate is set forth in Secs. 412.308 through 412.352.
Although the operating update to the standardized amounts was affected
by section 301 of Public Law 106-554, the standard capital Federal rate
update remained unchanged (0.9 percent). The exceptions adjustment
factor was determined based on an estimate of the ratio of exception
payments to total capital payments. As a result of the fixed-cost
outlier threshold, which affects total capital payments, in order to
maintain budget neutrality for exception payments, we revised the
exception adjustment factor from 0.9785 to 0.9787. The national GAF/DRG
budget neutrality factor was also revised from 0.9979 to 0.9978. The
Puerto Rico GAF/DRG budget neutrality factor remained unchanged
(1.0037). Accordingly, as a result of the revisions to the capital
outlier reduction factor and the capital exceptions adjustment factor,
for discharges occurring on or after April 1, 2001, and before October
1, 2001, the national capital Federal rate was revised from $382.03 (65
FR 47127) to $380.85 and the Puerto Rico capital rate was revised from
$185.06 (65 FR 47127) to $184.61.
In accordance with Sec. 412.328(e), the hospital-specific rate is
determined using the update factor and the exceptions adjustment
factor. As a result of revising the exceptions adjustment factor to
account for the change to the fixed-loss outlier threshold resulting
from the special payment rule for FY 2001 provided for under section
301(b) of Public Law 106-554, for discharges occurring on or after
April 1, 2001, and before October 1, 2001, the cumulative net
adjustment to the hospital-specific rate was revised from 1.0147 (65 FR
47124) to 1.0145. For discharges occurring on or after April 1, 2001,
and before October 1, 2001, the hospital-specific rate was determined
by multiplying the FY 2000 hospital-specific rate by the cumulative net
adjustment of 1.0145.
B. Calculation of Inpatient Capital-Related Prospective Payments for FY
2002
With the end of the capital prospective payment system transition
period, all hospitals (except ``new'' hospitals under Sec. 412.324(b))
will be paid based on 100 percent of the Federal rate in FY 2002. 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 adjustments applicable to the hospital, by
multiplying the hospital's GAF, disproportionate share adjustment
factor, and IME adjustment factor, when appropriate.
For purposes of calculating payments for each discharge during FY
2002, the standard Federal rate is adjusted as follows: (Standard
Federal Rate) x (DRG weight) x (GAF) x (Large Urban Add-on, if
applicable) x (COLA adjustment for hospitals located in Alaska and
Hawaii) x (1 + Disproportionate Share Adjustment Factor + IME
Adjustment Factor, if applicable). The result is the adjusted Federal
rate.
Hospitals also may receive outlier payments for those cases that
qualifyFY 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. The outlier thresholds for FY 2002 are in section
II.A.4.c. of this Addendum. For FY 2002, a case qualifies as a cost
outlier if the cost for the case plus the IME and DSH payments is
greater than the prospective payment rate for the DRG plus $21,025.
During the capital prospective payment system transition period, a
hospital also may receive an additional payment under the regular
exceptions process through its cost reporting period beginning before
October 1, 2001, but ending in FY 2002 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(c). Under
Sec. 412.348(d), the amount of a regular 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
[[Page 39952]]
cumulative minimum payment is deducted from the additional payment that
would otherwise be payable for a cost reporting period.
An eligible hospital may qualify for a special exception payment
under Sec. 412.348(g) for up through the 10th year beyond the end of
the capital transition period if it meets (1) a project need
requirement 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 DSH patient percentage of at least 20.2
percent, and hospitals that have a combined Medicare and Medicaid
inpatient utilization of at least 70 percent. Under Sec. 412.348(g)(8),
the amount of a special exceptions payment is determined by comparing
the cumulative payments made to the hospital under the capital
prospective payment system to the cumulative minimum payment level.
This amount is offset by (1) any amount by which a hospital's
cumulative capital payments exceed its cumulative minimum payment
levels applicable under the regular exceptions process for cost
reporting periods beginning during which the hospital has been subject
to the capital prospective payment system; and (2) any amount by which
a hospital's current year operating and capital payments (excluding 75
percent of operating DSH payments) exceed its operating and capital
costs. The minimum payment level is 70 percent for all eligible
hospitals under Sec. 412.348(g).
New hospitals, as defined under Sec. 412.300, 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 through the remainder of the transition
period, 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.
C. 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 Company 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 discussion of the cost
category weights in the CIPI was in the final rule with comment period
for FY 1998 published on August 29, 1997 (62 FR 46050).
2. Forecast of the CIPI for Federal Fiscal Year 2002
We are forecasting the CIPI to increase 0.7 percent for FY 2002.
This reflects a projected 1.4 percent increase in vintage-weighted
depreciation prices (building and fixed equipment, and movable
equipment) and a 3.3 percent increase in other capital expense prices
in FY 2002, partially offset by a 2.0 percent decline in vintage-
weighted interest rates in FY 2002. The weighted average of these three
factors produces the 0.7 percent increase for the CIPI as a whole.
IV. 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, a rehabilitation
hospital or hospital unit, or a long-term care hospital, the target
amount may not exceed the updated figure for the 75th percentile of
target amounts adjusted to take into account differences between
average wage-related costs in the area of the hospital and the national
average of such costs within the same class of hospital 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, 1998 and before October 1,
2002, the update factor for a hospital or unit depends on the
hospital's or hospital unit's costs in relation to the ceiling for the
most recent cost reporting period for which information is available.
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 2002
for hospitals and hospital units excluded from the prospective payment
system is 3.3 percent. Therefore, the update to a hospital's target
amount for its cost reporting period beginning in FY 2002 would be
between 0.8 and 3.3 percent, or 0 percent, depending on the
[[Page 39953]]
hospital's or unit's costs in relation to its rate-of-increase limit.
In addition, Sec. 413.40(c)(4)(iii) requires that for cost
reporting periods beginning on or after October 1, 1998, and before
October 1, 2002, 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.
Section 1886(b)(3)(H) of the Act, as amended by section 121 of
Public Law 106-113, provides for an appropriate wage adjustment to the
caps on the target amounts for psychiatric hospitals and units,
rehabilitation hospitals and units, and long-term care hospitals,
effective for cost reporting periods beginning on or after October 1,
1999, through September 30, 2002. On August 1, 2000, we published an
interim final rule with comment period that implemented this provision
for cost reporting periods beginning on or after October 1, 1999 and
before October 1, 2000 (65 FR 47026) and a final rule that implemented
the provision for cost reporting periods beginning on or after October
1, 2000, and before October 1, 2001 (65 FR 47054). This final rule
addresses the wage adjustment to the caps for cost reporting periods
beginning on or after October 1, 2001.
As discussed in section VI. of the preamble of this final rule, the
cap on the target amount per discharge is determined by adding the
hospital's nonlabor-related portion of the national 75th percentile cap
to its wage-adjusted, labor-related portion of the national 75th
percentile cap (the labor-related portion of costs equals 0.71553 and
the nonlabor-related portion of costs equals 0.28447). A hospital's
wage-adjusted, labor-related portion of the target amount is calculated
by multiplying the labor-related portion of the national 75th
percentile cap for the hospital's class by the wage index under the
hospital inpatient prospective payment system (see Sec. 412.63),
without taking into account reclassifications under sections
1886(d)(8)(B) and (d)(10) of the Act.
As discussed in section VI. of the preamble of this final rule, we
have made an adjustment to the caps on target amounts for new and
existing excluded hospitals and units. In calculating the wage-adjusted
caps on target amounts for new and existing excluded and units for FY
2001, we inadvertently made an error. In wage neutralizing FY 1996
target amounts, we used the FY 2000 hospital inpatient prospective
payment system wage index published in Tables 4A and 4B of the July 30,
1999 final rule (64 FR 41585 through 41593), which is based on wage
data after taking into account geographic reclassifications under
section 1886(d)(8) of the Act. We have used pre-reclassified wage data
in our recalculation of the caps for FY 2002. We recalculated both the
limits for new excluded hospitals and units and the caps for existing
excluded hospitals and units, using the same wage index used under the
prospective payment system for skilled nursing facilities (SNF) as
shown in Table 7 of the July 30, 1999 SNF final rule (64 FR 41690). We
do not anticipate a significant impact on overall payments to these
hospitals and units.
Section 307(a) of Public Law 106-554 amended section 1886(b)(3) of
the Act to provide for a 2-percent increase to the wage-adjusted 75th
percentile cap on the target amount for long-term care hospitals,
effective for cost reporting periods beginning during FY 2001. This
provision is applicable to long-term care hospitals that were subject
to the cap for existing excluded hospitals and units, as specified in
Sec. 413.40(c).
In addition to the increase to the cap on the target amounts for
long-term care hospitals, section 307(a) of Public Law 106-554 amended
section 1886(b)(3)(A) of the Act to make the section applicable to all
long-term care hospitals, effective for cost reporting periods
beginning during FY 2001. This provision requires a revision to the
determination of each long-term care hospital's FY 2001 target amount
as specified in Sec. 413.40(c)(4). For cost reporting periods beginning
during FY 2001, the hospital-specific target amount otherwise
determined for a long-term care hospital as specified under
Sec. 413.40(c)(4)(ii) is multiplied by 1.25 (that is, increased by 25
percent). However, the revised FY 2001 target amount for a long-term
care hospital cannot exceed its wage-adjusted national cap as required
by section 1886(b)(3) of the Act, as amended by section 307(a) of
Public Law 106-554.
For cost reporting periods beginning in FY 2002, in the May 4, 2001
proposed rule, we included the following proposed caps:
------------------------------------------------------------------------
Labor- Nonlabor-
Class of excluded hospital or unit related related
share share
------------------------------------------------------------------------
Psychiatric................................... $8,404 $ 3,341
Rehabilitation................................ $15,689 $6,237
Long-Term Care................................ $31,399 $12,483
------------------------------------------------------------------------
In this final rule, using updated data, we have recalculated the
proposed caps for cost reporting periods beginning in FY 2002. The
final FY 2002 caps are listed below:
------------------------------------------------------------------------
Labor- Nonlabor-
Class of excluded hospital or unit related related
shae share
------------------------------------------------------------------------
Psychiatric................................... $8,429 $3,351
Rehabilitation................................ $15,736 $6,256
Long-Term Care................................ $31,490 $12,519
------------------------------------------------------------------------
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.
[[Page 39954]]
V. 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 and 5 that were first used in the September 1, 1983 initial
prospective payment final rule (48 FR 39844). Tables 1A, 1C, 1D, 2, 3A,
3B, 4A, 4B, 4C, 4F, 4G, 4H, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B,
8A, and 8B are presented below. The tables presented below are as
follows:
Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico,
Labor/Nonlabor
Table 1D--Capital Standard Federal Payment Rate
Table 2--Hospital Average Hourly Wage for Federal Fiscal Years 2000
(1996 Wage Data), 2001 (1997 Wage Data) and 2002 (1998 Wage Data) Wage
Indexes and 3-Year Average of Hospital Average Hourly Wages
Table 3A--FY 2002 and 3-Year Average Hourly Wage for Urban Areas
Table 3B--FY 2002 and 3-Year Average Hourly Wage for Rural Areas
Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That Are Reclassified
Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment
Factor (GAF)
Table 4G--Pre-Reclassified Wage Index for Urban Areas
Table 4H--Pre-Reclassified Wage Index for Rural Areas
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting
Factors, Geometric and Arithmetic Mean Length of Stay
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Invalid Procedure Codes
Table 6E--Revised Diagnosis Code Titles
Table 6F--Revised Procedure Code Titles
Table 6G--Additions to the CC Exclusions List
Table 6H--Deletions to the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 2000 MedPAR Update 3/01 GROUPER V18.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 2000 MedPAR Update 3/01 GROUPER V19.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) July 2001
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) July 2001
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large Urban Areas Other Areas
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$2,955.44 $1,201.30 $2,908.65 $1,182.27
------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large Urban Areas Other Areas
---------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National PR..................................... $2,929.57 $1,190.78 $2,929.57 $1,190.78
Puerto Rico..................................... 1,420.07 571.61 1,397.59 562.56
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................ $390.74
Puerto Rico............................................. 187.73
------------------------------------------------------------------------
--------------------
* Asterisk denotes wage data not available for the provider that year.
** The 3-year average hourly wage is weighted by salaries and hours.
[[Page 39954]]
Table 2.--Hospital Average Hourly Wage for Federal Fiscal Years 2000 (1996 Wage Data), 2001 (1997 Wage Data) and
2002 (1998 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages
----------------------------------------------------------------------------------------------------------------
Average**
Average Average Average Hourly
Provider No. Hourly Hourly Hourly Wage (3
Wage FY 00 Wage FY 01 Wage FY 02 yrs)
----------------------------------------------------------------------------------------------------------------
010001...................................................... 15.8484 16.4088 17.4467 16.5711
010004...................................................... 15.0194 17.9732 19.0010 17.1863
010005...................................................... 16.2615 17.5985 18.6554 17.4986
010006...................................................... 17.3081 16.7480 17.6115 17.2150
010007...................................................... 14.8048 15.4798 15.6788 15.3288
[[Page 39955]]
010008...................................................... 17.6549 14.7443 17.4728 16.6080
010009...................................................... 17.5328 18.7731 18.4979 18.2633
010010...................................................... 15.9090 16.4468 16.4664 16.2848
010011...................................................... 20.6261 20.7972 22.4292 21.2601
010012...................................................... 19.2992 17.7171 15.8686 17.5430
010015...................................................... 18.3461 15.4510 19.1178 17.5372
010016...................................................... 16.1311 17.2473 20.2198 17.8844
010018...................................................... 18.9617 17.6449 18.9388 18.5180
010019...................................................... 15.4910 16.3493 17.0856 16.3311
010021...................................................... 14.6297 16.2919 15.1241 15.3000
010022...................................................... 20.5050 18.5879 17.6435 18.8422
010023...................................................... 16.2581 16.1025 16.3209 16.2283
010024...................................................... 16.0263 16.2900 15.9034 16.0692
010025...................................................... 14.5311 15.1356 15.1548 14.9441
010027...................................................... 14.9278 11.7900 16.8595 14.1053
010029...................................................... 16.4103 17.6461 18.3605 17.4403
010031...................................................... 18.0194 18.7835 18.6402 18.4877
010032...................................................... 12.6540 12.5995 15.3590 13.6017
010033...................................................... 19.6797 20.3923 21.2986 20.4581
010034...................................................... 14.7342 15.0959 15.3639 15.0606
010035...................................................... 17.4788 20.1853 15.9439 17.6916
010036...................................................... 17.2880 17.8140 17.7166 17.6061
010038...................................................... 18.3309 18.2671 19.6098 18.7632
010039...................................................... 18.8080 20.1045 20.3406 19.7778
010040...................................................... 19.1030 18.9376 20.0983 19.3415
010043...................................................... 16.2022 30.7489 18.6640 19.9982
010044...................................................... 17.0229 22.0091 24.0265 20.8906
010045...................................................... 15.0065 15.2200 17.0417 15.7248
010046...................................................... 17.1822 17.3970 18.9737 17.8750
010047...................................................... 16.3803 13.3521 15.4190 15.2030
010049...................................................... 14.4823 14.7590 15.5246 14.9487
010050...................................................... 15.4159 18.5163 17.9830 17.2796
010051...................................................... 9.9390 11.9275 11.8108 11.1940
010052...................................................... 13.8649 16.5486 18.0653 16.1248
010053...................................................... 13.1778 14.6267 15.5649 14.5406
010054...................................................... 17.1246 18.5103 19.4955 18.4846
010055...................................................... 18.1930 18.9526 18.8590 18.6711
010056...................................................... 19.0783 19.2175 19.6577 19.3204
010058...................................................... 12.7809 16.1702 16.9715 15.1274
010059...................................................... 18.1886 19.1286 18.8020 18.7124
010061...................................................... 15.9215 14.9547 14.5003 15.1112
010062...................................................... 13.5690 14.7732 12.3259 13.5151
010064...................................................... 20.8966 20.4139 19.5256 20.2712
010065...................................................... 15.6357 16.4049 16.8752 16.3279
010066...................................................... 12.0681 15.4317 13.1559 13.4757
010068...................................................... 18.7367 12.0525 18.6925 15.8875
010069...................................................... 13.5684 13.8636 14.7211 14.0429
010072...................................................... 14.3481 14.9526 16.2339 15.1957
010073...................................................... 12.8328 13.8601 14.1273 13.6015
010078...................................................... 17.7110 17.9202 18.1363 17.9248
010079...................................................... 16.8701 16.4421 17.0648 16.7882
010080...................................................... 13.8473 * * 13.8473
010081...................................................... 16.9823 18.9474 17.2996 17.7081
010083...................................................... 16.2146 16.8933 18.0312 17.0916
010084...................................................... 18.7794 18.4965 18.7769 18.6812
010085...................................................... 18.8696 18.4744 19.9023 19.0736
010086...................................................... 14.9255 16.6694 16.5711 16.0968
010087...................................................... 18.3889 19.0033 18.0567 18.5192
010089...................................................... 16.6090 16.8042 17.7800 17.0521
010090...................................................... 18.1121 18.3866 18.9445 18.4882
010091...................................................... 16.3620 13.9405 17.0799 15.6820
010092...................................................... 16.4980 16.9900 17.8144 17.1322
010094...................................................... 18.5603 * * 18.5603
[[Page 39956]]
010095...................................................... 11.8993 12.4525 12.2597 12.2090
010097...................................................... 12.8955 13.0413 12.7286 12.8889
010098...................................................... 14.2787 15.9165 14.0300 14.6833
010099...................................................... 15.9309 15.9874 15.5619 15.8073
010100...................................................... 15.4826 17.2011 17.9430 16.9229
010101...................................................... 15.4173 15.3859 14.4625 15.0781
010102...................................................... 12.7251 13.7933 13.8136 13.4259
010103...................................................... 19.3115 17.9358 17.7242 18.3325
010104...................................................... 18.0997 17.7126 16.8457 17.5501
010108...................................................... 20.7914 17.9017 19.4617 19.3047
010109...................................................... 14.0870 15.3107 14.6752 14.6907
010110...................................................... 15.9066 15.6317 15.8283 15.7917
010112...................................................... 15.1056 15.1401 16.8271 15.6716
010113...................................................... 17.2440 16.9683 16.8936 17.0309
010114...................................................... 17.2612 15.2454 17.0760 16.4722
010115...................................................... 13.7524 14.6268 14.2261 14.2120
010118...................................................... 16.6889 18.8477 17.0834 17.5145
010119...................................................... 18.1707 18.8024 19.3942 18.9605
010120...................................................... 17.0332 17.2336 18.2567 17.5146
010121...................................................... 15.1806 14.6444 14.5262 14.8160
010123...................................................... 18.1604 16.7344 19.2140 17.9949
010124...................................................... 16.2666 16.2846 16.7465 16.4273
010125...................................................... 14.4153 15.5304 16.0136 15.3557
010126...................................................... 17.6405 19.5710 19.1065 18.7347
010127...................................................... 19.6095 19.5190 18.2786 19.1726
010128...................................................... 12.5747 14.5056 14.4322 13.6385
010129...................................................... 14.4267 14.7286 16.1733 15.1385
010130...................................................... 16.3465 16.6809 19.5573 17.3907
010131...................................................... 17.9076 17.8260 20.1883 18.6602
010134...................................................... 10.7817 18.8835 19.9856 15.8677
010137...................................................... 15.9348 12.1217 20.5828 15.9236
010138...................................................... 12.1295 12.8675 14.5254 13.1763
010139...................................................... 19.9487 19.0001 20.4331 19.7578
010143...................................................... 15.7144 16.7911 17.6212 16.7651
010144...................................................... 17.1211 17.1320 18.2040 17.4771
010145...................................................... 20.7460 20.8434 20.5895 20.7209
010146...................................................... 18.8561 18.5198 19.1415 18.8309
010148...................................................... 14.6443 12.2214 15.8349 13.9784
010149...................................................... 17.0836 18.6333 18.0156 17.9216
010150...................................................... 16.9749 17.8951 18.9359 17.9332
010152...................................................... 17.3835 17.8306 18.7677 18.0088
010155...................................................... 16.7028 9.0300 15.0689 12.5183
010158...................................................... * 17.3227 18.3957 17.8637
020001...................................................... 27.9690 28.1747 28.0394 28.0627
020002...................................................... 26.9145 24.5815 25.1987 25.5092
020004...................................................... 26.3979 30.5667 25.4679 27.5927
020005...................................................... 29.0068 30.2920 29.2378 29.5337
020006...................................................... 26.7706 31.2404 28.1417 28.8630
020007...................................................... 24.9555 27.8319 32.3852 28.0097
020008...................................................... 30.4712 29.4146 30.8691 30.2487
020009...................................................... 23.1801 20.1930 18.4660 20.3801
020010...................................................... 18.6417 23.6727 22.7559 21.4818
020011...................................................... 29.4697 30.4727 28.0658 29.3006
020012...................................................... 23.9259 24.8543 25.5320 24.7635
020013...................................................... 26.8172 23.8847 28.1557 26.0576
020014...................................................... 24.0932 27.3823 24.5875 25.3179
020017...................................................... 24.9714 26.8319 28.0572 26.6405
020024...................................................... 22.7263 24.0872 25.3205 24.0621
020025...................................................... 27.1529 21.7557 20.2583 22.6334
030001...................................................... 19.8695 20.3673 21.7869 20.6506
030002...................................................... 21.6263 21.5977 21.8375 21.6886
030003...................................................... 23.6722 23.4833 22.6804 23.3063
030004...................................................... 17.7333 14.0711 15.5478 15.4308
[[Page 39957]]
030006...................................................... 17.6409 18.2668 20.0273 18.6274
030007...................................................... 18.5602 19.6708 21.5169 19.9379
030008...................................................... * 22.2758 22.2190 22.2524
030009...................................................... 17.9343 18.1794 18.7557 18.2786
030010...................................................... 18.7997 19.0907 19.5123 19.1422
030011...................................................... 20.0784 19.2973 19.4310 19.5785
030012...................................................... 19.4245 18.9918 20.6585 19.6997
030013...................................................... 21.0182 20.7458 20.0535 20.5870
030014...................................................... 19.4697 19.9315 19.7966 19.7342
030016...................................................... 20.5606 19.3967 19.4785 19.8559
030017...................................................... 20.4185 22.8765 21.7938 21.6805
030018...................................................... 18.9115 20.2032 20.8980 20.0193
030019...................................................... 19.9211 21.7005 21.2540 20.9846
030022...................................................... 15.7886 19.2966 19.5794 17.6713
030023...................................................... 22.4365 23.6697 24.1678 23.4686
030024...................................................... 21.6692 22.2541 23.6009 22.5290
030025...................................................... 17.6759 12.7254 11.9894 13.7385
030027...................................................... 17.5796 15.7554 17.6555 16.9563
030030...................................................... 21.6249 20.8303 21.6932 21.3795
030033...................................................... 16.8396 20.0044 20.2820 18.9069
030034...................................................... 19.0868 16.8241 20.8689 18.8279
030035...................................................... 19.7153 19.2781 20.0226 19.6580
030036...................................................... 18.9449 20.7567 21.6371 20.4743
030037...................................................... 21.4376 22.8266 23.7615 22.6712
030038...................................................... 22.0777 22.6776 22.9822 22.5885
030040...................................................... 17.9722 18.5456 19.7636 18.7537
030041...................................................... 17.4389 15.8921 18.8717 17.2718
030043...................................................... 20.7721 20.9341 20.5598 20.7468
030044...................................................... 16.4654 16.8649 17.6575 17.0214
030047...................................................... 19.6916 22.6401 21.4412 21.2271
030049...................................................... 19.0896 19.0881 19.3580 19.1639
030054...................................................... 14.4861 15.3338 15.0657 14.9801
030055...................................................... 18.2751 16.3613 20.2991 18.2684
030059...................................................... 21.7100 24.0465 22.6279 22.7570
030060...................................................... 16.7661 19.2461 18.6313 18.2043
030061...................................................... 17.3470 18.9063 19.9047 18.7238
030062...................................................... 17.4825 17.6738 18.7172 17.9978
030064...................................................... 18.5391 19.5673 20.3837 19.5213
030065...................................................... 19.9277 20.5130 20.7838 20.4254
030067...................................................... 15.6207 14.4446 17.2778 15.7364
030068...................................................... 17.3482 17.3614 17.7208 17.4823
030069...................................................... 19.0013 19.0961 21.0936 19.7255
030080...................................................... 19.9865 20.5144 20.6581 20.3684
030083...................................................... 23.6433 23.3355 23.5229 23.4991
030085...................................................... 17.8402 21.0954 20.8690 19.9451
030086...................................................... 18.5030 19.5436 * 19.0352
030087...................................................... 20.0469 21.4084 21.9465 21.1838
030088...................................................... 19.5772 19.8682 20.5340 20.0152
030089...................................................... 19.9018 20.4019 20.9516 20.4404
030092...................................................... 21.5628 20.6986 21.8308 21.3646
030093...................................................... 19.4688 19.7262 20.4314 19.9052
030094...................................................... 19.4773 21.6218 22.8123 21.4086
030095...................................................... 14.2499 13.7293 13.7664 13.9087
030099...................................................... 18.0747 16.1541 18.2263 17.4781
030100...................................................... * * 23.7609 23.7609
030101...................................................... * * 19.2547 19.2547
030102...................................................... * * 18.2413 18.2413
040001...................................................... 15.5735 15.1624 16.9178 15.8741
040002...................................................... 14.0865 13.0592 15.1107 14.0333
040003...................................................... 14.0027 14.2089 15.5740 14.5731
040004...................................................... 17.2926 17.8476 17.9034 17.6718
040005...................................................... 12.8825 13.2597 11.1318 12.3937
040007...................................................... 19.5299 21.9583 18.6998 19.9568
[[Page 39958]]
040008...................................................... 12.6974 15.3040 14.7985 14.3087
040010...................................................... 17.6231 18.6023 19.4913 18.6031
040011...................................................... 12.2654 14.5319 16.0995 14.1756
040014...................................................... 15.3853 17.6340 18.1434 17.0051
040015...................................................... 14.6045 16.5891 15.5207 15.5649
040016...................................................... 17.5431 19.0295 20.2321 18.9152
040017...................................................... 14.9533 13.5098 15.4736 14.6592
040018...................................................... 17.5602 17.6027 18.7463 17.9749
040019...................................................... 25.7080 22.6769 23.4163 23.8479
040020...................................................... 14.8059 16.4827 18.9844 16.6335
040021...................................................... 16.4628 17.6398 19.6835 17.8176
040022...................................................... 16.0006 17.0397 20.8281 17.7640
040024...................................................... 15.7282 14.4541 17.6607 15.9615
040025...................................................... 10.9496 11.5079 13.4705 11.8847
040026...................................................... 18.2398 19.5563 19.7924 19.1863
040027...................................................... 14.5406 16.0975 17.4431 16.0716
040028...................................................... 12.8409 14.6584 13.9946 13.7921
040029...................................................... 17.7777 17.8787 21.1370 18.9480
040030...................................................... 14.1541 13.5428 11.2402 12.7784
040032...................................................... 13.3280 13.7030 13.2872 13.4471
040035...................................................... 11.2123 12.8300 10.9569 11.6408
040036...................................................... 17.9080 18.9757 20.2012 19.0415
040037...................................................... 13.4815 14.6559 14.0941 14.0704
040039...................................................... 13.8386 14.3576 14.7177 14.3115
040040...................................................... 17.4283 18.0895 19.1984 18.2668
040041...................................................... 13.3613 15.9896 16.4624 15.2103
040042...................................................... 14.6641 15.2142 15.2057 15.0333
040044...................................................... 11.4422 12.6275 13.3501 12.5381
040045...................................................... 18.7724 14.9429 16.2469 16.4870
040047...................................................... 16.3948 16.8654 17.5336 16.9538
040048...................................................... 15.8203 * * 15.8203
040050...................................................... 11.7934 13.3818 14.0036 13.0341
040051...................................................... 16.2803 15.8627 16.6039 16.2390
040053...................................................... 15.8193 16.3610 15.0219 15.7502
040054...................................................... 15.0412 15.3219 14.2577 14.8844
040055...................................................... 16.1029 17.1269 18.0414 17.0866
040058...................................................... 15.6706 17.6766 16.4278 16.6344
040060...................................................... 11.4686 12.8148 17.9805 13.6105
040062...................................................... 17.2757 18.2048 17.8902 17.8204
040064...................................................... 12.4007 10.7255 11.5029 11.4801
040066...................................................... 17.6429 18.3377 19.7144 18.5416
040067...................................................... 13.4930 14.6014 14.4741 14.1956
040069...................................................... 16.1147 17.5052 17.0026 16.8681
040070...................................................... 15.4757 16.9027 16.9700 16.4358
040071...................................................... 16.3022 16.9610 17.6144 16.9553
040072...................................................... 15.8425 16.0895 17.4960 16.4940
040074...................................................... 17.3819 18.3224 18.7542 18.1968
040075...................................................... 12.7496 13.3623 14.0975 13.3977
040076...................................................... 18.5512 19.0732 20.5840 19.3801
040077...................................................... 12.4625 12.9211 13.9114 13.0965
040078...................................................... 17.8573 18.7600 18.5821 18.4100
040080...................................................... 15.7397 19.2461 19.3707 18.0636
040081...................................................... 10.6791 11.3169 11.1332 11.0311
040082...................................................... 16.5127 16.2152 15.1331 15.9302
040084...................................................... 17.2469 17.2613 17.7295 17.4070
040085...................................................... 15.7765 16.8957 16.5216 16.3838
040088...................................................... 15.6710 17.9636 17.1624 16.9372
040090...................................................... 17.5503 17.8282 19.0824 18.0989
040091...................................................... 17.0444 19.8700 20.1378 18.8893
040093...................................................... 12.9010 12.3537 13.9741 13.0114
040100...................................................... 14.9688 14.7587 15.6833 15.1704
040105...................................................... 14.2409 15.3319 14.3896 14.6616
040106...................................................... 15.4000 15.6545 18.1341 16.4515
[[Page 39959]]
040107...................................................... 19.6184 18.8120 17.8628 18.6841
040109...................................................... 13.9807 14.6266 16.6278 15.0815
040114...................................................... 18.3133 18.8743 21.1231 19.3828
040116...................................................... 19.5695 20.2716 * 19.9151
040118...................................................... 17.4300 19.3720 18.2123 18.3407
040119...................................................... 15.3847 15.5338 16.9407 15.9572
040124...................................................... 17.2547 19.1349 19.2889 18.5723
040126...................................................... 11.6845 12.5368 11.6517 11.9404
040132...................................................... 13.1760 17.5179 10.3875 13.4483
040134...................................................... * 18.0787 19.0185 18.5701
040135...................................................... * 22.6761 23.0084 22.8797
050002...................................................... 27.6006 37.8295 36.9630 33.5586
050006...................................................... 19.5272 19.5594 18.2061 19.0382
050007...................................................... 29.5398 30.7126 30.8676 30.4910
050008...................................................... 25.8570 26.2458 26.3682 26.1654
050009...................................................... 26.2506 26.8159 28.4734 27.2303
050013...................................................... 24.8541 23.2201 28.0569 25.1985
050014...................................................... 24.5302 22.8478 23.6745 23.6450
050015...................................................... 25.3838 26.2481 27.7731 26.4938
050016...................................................... 20.1542 20.5566 21.2045 20.6377
050017...................................................... 23.6639 23.9625 25.6178 24.4113
050018...................................................... 14.6622 15.4721 15.2903 15.1444
050021...................................................... 28.5003 25.8966 * 27.2682
050022...................................................... 22.9583 24.0318 24.5254 23.8802
050024...................................................... 20.3427 21.3989 22.4274 21.4070
050025...................................................... 21.9952 23.3896 24.8245 23.3764
050026...................................................... 28.6850 27.8736 23.1904 26.4206
050028...................................................... 16.4531 16.4671 17.6138 16.8496
050029...................................................... 23.2911 25.1259 24.6839 24.3441
050030...................................................... 21.0096 20.9812 21.5621 21.1955
050032...................................................... 22.5868 25.2010 24.3598 24.0616
050033...................................................... 24.5609 24.9328 32.0179 27.2378
050036...................................................... 20.4703 21.2420 21.8239 21.1856
050038...................................................... 27.8274 28.6528 29.9698 28.8293
050039...................................................... 22.2524 22.7117 22.8288 22.6033
050040...................................................... 30.6664 32.1287 30.2607 31.0150
050042...................................................... 22.2343 24.8067 24.5260 23.8317
050043...................................................... 33.2286 32.9958 33.8255 33.3456
050045...................................................... 20.7307 19.8831 21.1474 20.5973
050046...................................................... 31.3831 25.3185 25.2005 27.4555
050047...................................................... 29.4412 29.9255 29.9580 29.7840
050051...................................................... 17.8401 17.8945 18.7809 18.1179
050054...................................................... 19.3686 20.7212 22.0982 20.7075
050055...................................................... 29.0872 29.3984 29.2730 29.2593
050056...................................................... 23.8507 27.4321 23.8396 24.9757
050057...................................................... 21.7581 21.1554 20.7420 21.1969
050058...................................................... 25.7261 23.1641 23.3009 23.9601
050060...................................................... 20.9219 20.7747 20.5450 20.7207
050061...................................................... 23.7443 23.5454 24.5488 23.9503
050063...................................................... 23.0724 24.8851 25.7593 24.5061
050065...................................................... 21.1848 24.0420 24.6290 23.1479
050066...................................................... 21.4187 16.5725 16.1649 17.6784
050067...................................................... 21.3029 23.1966 25.8857 23.3989
050068...................................................... 28.4804 20.6851 19.3615 22.4409
050069...................................................... 29.2980 25.9420 24.6153 26.4351
050070...................................................... 32.5964 32.5166 34.0721 33.0817
050071...................................................... 33.1379 33.1850 34.4367 33.6139
050072...................................................... 32.9660 33.2858 39.7321 35.2928
050073...................................................... 34.6111 33.3922 32.8555 33.5664
050075...................................................... 33.5246 33.9095 33.7160 33.7090
050076...................................................... 33.8835 27.7797 33.9752 31.7128
050077...................................................... 23.2986 24.1019 24.1404 23.8541
050078...................................................... 22.8023 23.0736 24.3150 23.3638
[[Page 39960]]
050079...................................................... 34.4253 33.2432 30.0167 32.3461
050082...................................................... 21.7004 22.1009 23.7617 22.5498
050084...................................................... 23.0966 23.5866 25.4517 24.0054
050088...................................................... 24.0634 20.8406 24.9641 23.1779
050089...................................................... 20.0194 20.9117 22.8450 21.2533
050090...................................................... 23.8969 23.4097 24.6070 23.9625
050091...................................................... 22.2220 25.2792 23.7713 23.6457
050092...................................................... 15.3841 16.7969 17.1211 16.4241
050093...................................................... 24.0837 25.2130 25.6647 24.9860
050095...................................................... 33.3761 33.6718 30.4847 32.6392
050096...................................................... 21.6752 20.0487 22.7394 21.3870
050097...................................................... 22.6147 16.7054 22.5991 20.1968
050099...................................................... 24.2921 24.8091 25.3722 24.8349
050100...................................................... 30.0552 29.8758 25.2031 28.1754
050101...................................................... 30.0132 31.0264 31.8957 30.9871
050102...................................................... 21.2947 22.2937 24.0014 22.4745
050103...................................................... 25.3384 24.7932 25.4133 25.1832
050104...................................................... 25.4407 25.5797 26.9726 25.9841
050107...................................................... 21.7649 21.2690 22.2019 21.7497
050108...................................................... 25.2116 23.5564 25.1758 24.5678
050109...................................................... 26.4768 * * 26.4768
050110...................................................... 20.1769 20.1870 19.9589 20.1175
050111...................................................... 21.7397 21.5487 20.7897 21.3840
050112...................................................... 26.2922 25.3015 26.8182 26.1335
050113...................................................... 27.7805 28.8420 28.5224 28.4025
050114...................................................... 25.9073 24.7286 26.6757 25.7599
050115...................................................... 21.0499 21.3291 23.0182 21.8124
050116...................................................... 25.5919 25.2130 24.9196 25.2412
050117...................................................... 20.4379 23.3612 22.2123 21.9903
050118...................................................... 23.9976 23.7698 23.7129 23.8243
050121...................................................... 18.8818 19.5252 18.7272 19.0416
050122...................................................... * 26.3172 26.9546 26.6358
050124...................................................... 23.0193 22.7736 24.5069 23.3667
050125...................................................... 24.0434 29.6147 32.0230 28.3742
050126...................................................... 23.8424 23.9247 24.6752 24.1448
050127...................................................... 19.7654 22.1937 20.9027 20.9520
050128...................................................... 24.1801 25.7240 26.6132 25.5185
050129...................................................... 27.1586 26.5030 24.0108 25.7227
050131...................................................... 29.0570 31.0732 32.5462 30.8106
050132...................................................... 22.9139 24.0834 24.0173 23.6527
050133...................................................... 24.4011 24.9746 23.2093 24.1354
050135...................................................... 27.0341 23.2361 24.7157 24.9796
050136...................................................... 24.4336 24.7921 24.7280 24.6450
050137...................................................... 30.0725 32.6507 32.9192 31.8970
050138...................................................... 37.4088 37.3286 38.1584 37.6483
050139...................................................... 31.3785 32.9351 31.4984 31.9286
050140...................................................... 33.6644 34.1499 32.7609 33.4990
050144...................................................... 25.7483 27.8751 27.4069 26.9409
050145...................................................... 33.0620 32.3857 34.5185 33.3152
050148...................................................... 21.0584 21.9211 20.0971 20.9748
050149...................................................... 23.3754 24.6078 26.8674 24.8666
050150...................................................... 23.4777 24.9073 24.6596 24.3771
050152...................................................... 27.7504 34.0766 33.3305 31.5833
050153...................................................... 29.5915 30.5714 32.3389 30.8441
050155...................................................... 22.9420 21.0257 25.3354 22.9852
050158...................................................... 27.9789 27.5623 28.6071 28.0313
050159...................................................... 25.2105 23.2912 22.5313 23.6099
050167...................................................... 21.6778 21.9128 21.8796 21.8226
050168...................................................... 25.2504 23.3511 25.1937 24.5830
050169...................................................... 24.6361 22.3888 24.8407 23.8796
050170...................................................... 22.1989 23.9574 24.3654 23.4164
050172...................................................... 17.6976 20.1841 19.6120 19.1630
050173...................................................... 23.3255 24.5545 24.8694 24.1923
[[Page 39961]]
050174...................................................... 31.2136 30.2140 30.2775 30.5443
050175...................................................... 27.7875 27.2806 24.7548 26.2477
050177...................................................... 20.2485 21.7943 21.1396 21.0728
050179...................................................... 19.2861 21.7175 23.8868 21.4573
050180...................................................... 32.1883 31.8947 33.3257 32.5107
050183...................................................... 19.9765 20.3638 * 20.1665
050186...................................................... 21.9062 22.4155 23.6288 22.6119
050188...................................................... 27.4364 28.0918 28.2364 27.9460
050189...................................................... 23.2415 22.8687 27.4071 24.6245
050191...................................................... 26.7297 20.8321 25.3516 24.1885
050192...................................................... 17.8095 18.6701 14.1996 16.5873
050193...................................................... 23.7260 22.6316 24.9444 23.7567
050194...................................................... 28.2701 29.7371 29.5678 29.1714
050195...................................................... 34.7789 35.5621 36.9068 35.7823
050196...................................................... 16.6866 18.5180 18.2411 17.8430
050197...................................................... 31.4513 35.7449 32.4030 33.0882
050204...................................................... 24.3944 23.6105 22.7099 23.5849
050205...................................................... 21.1545 23.6831 24.1691 23.0778
050207...................................................... 20.8576 21.6214 22.9941 21.8243
050211...................................................... 31.2175 31.6084 31.7280 31.5153
050213...................................................... 20.7338 21.4806 21.4951 21.1847
050214...................................................... 20.8704 21.7335 24.0276 22.1888
050215...................................................... 28.4058 29.8563 35.0459 31.0290
050217...................................................... 19.8913 19.6010 20.2042 19.9076
050219...................................................... 25.4730 21.7444 21.2458 22.6404
050222...................................................... 27.0713 27.4809 23.3563 25.7959
050224...................................................... 23.7942 23.5316 23.5101 23.6043
050225...................................................... 20.7978 23.3480 21.6820 21.9144
050226...................................................... 26.9297 27.7315 24.4443 26.2380
050228...................................................... 30.3772 34.0711 34.2596 32.7722
050230...................................................... 25.3640 27.7357 26.6291 26.5638
050231...................................................... 25.5798 26.1508 26.7321 26.1759
050232...................................................... 23.3849 24.3072 24.5245 24.0793
050233...................................................... 31.3954 * * 31.3954
050234...................................................... 28.5188 25.7035 24.6126 26.2702
050235...................................................... 25.8595 25.2527 27.0922 26.0726
050236...................................................... 26.2723 26.9803 25.9458 26.4027
050238...................................................... 24.0043 24.2922 24.5823 24.2994
050239...................................................... 20.4071 22.6625 23.2711 22.0940
050240...................................................... 25.2540 26.3657 26.7620 26.0528
050241...................................................... 27.2198 26.3740 29.8345 27.7426
050242...................................................... 30.1432 31.1576 32.0829 31.1145
050243...................................................... 22.9123 28.9635 26.4627 26.1049
050245...................................................... 24.3969 23.8124 23.2716 23.7873
050248...................................................... 27.4214 26.2015 27.6457 27.0910
050251...................................................... 18.4990 21.6574 23.6360 21.1907
050253...................................................... 20.0658 16.0701 16.7540 17.4281
050254...................................................... 19.6899 19.3126 20.1176 19.7146
050256...................................................... 23.5302 23.6887 23.4835 23.5723
050257...................................................... 19.5923 15.2306 17.2596 17.1813
050260...................................................... 23.5201 23.2421 27.4234 24.5032
050261...................................................... 20.4496 20.0552 20.1040 20.2029
050262...................................................... 29.0054 28.8785 29.5550 29.1532
050264...................................................... 29.4542 32.1312 36.0331 32.4545
050267...................................................... 24.7464 26.2264 26.0401 25.6690
050270...................................................... 23.7260 24.0439 25.3757 24.3521
050272...................................................... 21.4374 22.4247 23.0587 22.2948
050274...................................................... 21.1943 20.0422 * 20.6204
050276...................................................... 28.5051 29.8624 33.3302 30.5715
050277...................................................... 22.3125 20.0520 26.0822 22.5131
050278...................................................... 23.8434 24.7787 23.9289 24.1853
050279...................................................... 21.0570 20.8444 21.8949 21.2309
050280...................................................... 24.4267 25.2149 25.6651 25.1337
[[Page 39962]]
050281...................................................... 18.5907 19.6888 24.2251 20.7934
050282...................................................... 24.4593 28.8261 25.4428 26.2214
050283...................................................... 27.8763 29.7734 31.7669 30.1598
050286...................................................... 17.8045 16.5708 19.4241 17.6805
050289...................................................... 26.7185 34.1393 30.4750 30.2632
050290...................................................... 26.3745 28.6231 29.6796 28.2631
050291...................................................... 26.4908 30.2748 29.4029 28.6899
050292...................................................... 22.4878 21.6243 20.8410 21.6183
050293...................................................... 19.1761 22.2963 24.1875 21.4642
050295...................................................... 20.7393 21.2892 21.7883 21.2665
050296...................................................... 25.3166 27.2948 28.3906 27.0098
050298...................................................... 20.5181 24.4477 23.2006 22.6781
050299...................................................... 25.7697 26.4543 25.5035 25.9187
050300...................................................... 22.7423 23.5116 25.9228 24.1102
050301...................................................... 26.0355 22.5201 21.1403 23.0323
050302...................................................... 29.2007 * * 29.2007
050305...................................................... 32.7082 34.5185 36.7908 34.7340
050307...................................................... 27.9830 17.2147 * 21.7503
050308...................................................... 28.4019 29.3803 28.9284 28.9113
050309...................................................... 24.4034 23.7884 25.3515 24.5133
050310...................................................... 20.6181 * * 20.6181
050312...................................................... 23.7936 26.7617 26.0015 25.5439
050313...................................................... 23.1009 21.7577 25.6827 23.5594
050315...................................................... 21.9227 24.7086 22.7359 23.0264
050317...................................................... 19.4479 21.6937 * 20.5789
050320...................................................... 30.6054 30.4101 32.4809 31.1252
050324...................................................... 26.2735 26.6049 25.3694 26.0738
050325...................................................... 23.2355 24.4862 23.6327 23.7872
050327...................................................... 22.8511 23.9484 25.6450 24.1469
050328...................................................... 23.1889 * * 23.1889
050329...................................................... 21.4125 19.7455 21.6984 20.9322
050331...................................................... 25.5252 22.2536 25.0230 24.1261
050333...................................................... 20.1468 19.4589 19.1449 19.5671
050334...................................................... 32.0169 34.2330 34.2557 33.5307
050335...................................................... 20.2013 23.0258 22.9926 22.0827
050336...................................................... 20.0980 20.7979 21.3402 20.7523
050342...................................................... 19.3524 20.1841 20.8255 20.1210
050343...................................................... 17.3394 17.2085 * 17.2799
050348...................................................... 20.7505 23.8779 25.1085 23.3219
050349...................................................... 15.0515 14.9754 15.0667 15.0310
050350...................................................... 25.0676 24.8340 26.4161 25.4163
050351...................................................... 24.6936 25.4791 24.8121 24.9948
050352...................................................... 23.5927 26.1380 26.4262 25.4187
050353...................................................... 23.2468 23.0564 23.2699 23.1944
050355...................................................... 17.1597 17.2778 21.0969 18.0157
050357...................................................... 23.6411 22.6545 24.5345 23.6386
050359...................................................... 20.4005 17.7907 21.7548 19.8316
050360...................................................... 31.7608 31.3526 31.7583 31.6236
050366...................................................... 21.3442 23.7528 19.6823 21.4770
050367...................................................... 29.4763 28.2805 30.7328 29.5063
050369...................................................... 24.2604 27.0548 26.2234 25.8174
050373...................................................... 26.6548 26.9776 27.8275 27.1333
050376...................................................... 25.3036 26.5840 28.0990 26.5882
050377...................................................... 25.6401 17.1764 17.0012 20.1035
050378...................................................... 22.2363 25.9810 26.9101 24.8709
050379...................................................... 15.4994 15.2022 18.4278 16.2767
050380...................................................... 30.5790 31.4343 31.9578 31.3600
050382...................................................... 26.1465 26.1398 25.9244 26.0725
050385...................................................... 25.9188 24.6083 * 25.2398
050388...................................................... 13.7863 19.1512 22.0122 17.5709
050390...................................................... 22.5668 25.0426 24.2700 23.9349
050391...................................................... 22.4881 18.9266 20.0615 20.3952
050392...................................................... 21.9324 21.6729 22.9430 22.1487
[[Page 39963]]
050393...................................................... 23.1387 25.6964 24.1981 24.3082
050394...................................................... 22.2424 23.0604 23.1526 22.8333
050396...................................................... 23.6322 24.0636 25.3729 24.3512
050397...................................................... 20.7698 20.2601 20.6397 20.5453
050401...................................................... 17.7807 20.7473 18.4593 18.9557
050404...................................................... 19.2754 17.3396 15.9839 17.4356
050406...................................................... 16.8931 17.3016 17.8596 17.3407
050407...................................................... 30.1222 29.9642 30.8346 30.2996
050410...................................................... 16.4735 17.6769 19.8508 17.8663
050411...................................................... 32.2364 34.8899 33.1943 33.4145
050414...................................................... 24.4243 24.2060 25.9723 24.9224
050417...................................................... 21.8884 21.5739 23.3005 22.2456
050419...................................................... 23.1162 23.7584 23.4936 23.4646
050420...................................................... 22.6819 22.3166 23.5438 22.8448
050423...................................................... 23.3296 17.3771 21.3552 20.6272
050424...................................................... 23.7788 22.8350 24.0727 23.5641
050425...................................................... 33.6911 32.8364 35.3712 34.0224
050426...................................................... 23.7082 25.2453 29.0120 25.8759
050427...................................................... 20.0698 20.1674 16.4330 18.6499
050430...................................................... 21.3428 23.8788 21.2275 22.2136
050432...................................................... 21.4984 24.4133 24.5630 23.4427
050433...................................................... 16.8035 17.4643 18.9021 17.7004
050434...................................................... 15.6348 19.7591 * 17.6624
050435...................................................... 32.9865 25.6676 23.3426 26.8858
050436...................................................... 16.3594 14.8121 * 15.5729
050438...................................................... 24.0828 25.0138 23.2583 24.1266
050440...................................................... 21.1100 23.5167 22.5400 22.3553
050441...................................................... 28.7067 28.9804 31.8774 29.8169
050443...................................................... 16.4308 19.9020 17.2875 17.7906
050444...................................................... 24.6741 21.4533 22.4530 22.8550
050446...................................................... 20.5383 20.4908 22.3422 21.1378
050447...................................................... 18.4183 17.9751 18.9851 18.4558
050448...................................................... 20.0757 19.7046 21.7718 20.5035
050449...................................................... 22.1784 23.8001 23.4614 23.1469
050454...................................................... 28.6857 28.7432 30.0792 29.2410
050455...................................................... 19.9209 20.1643 19.8577 19.9840
050456...................................................... 17.6229 20.1254 18.1585 18.5890
050457...................................................... 31.2489 34.4949 32.1910 32.6376
050459...................................................... 37.0914 * * 37.0914
050464...................................................... 22.3142 25.3292 25.7710 24.4665
050468...................................................... 23.1701 23.3050 22.2926 22.8998
050469...................................................... 23.4404 23.8759 24.5205 23.8915
050470...................................................... 17.0353 16.0292 16.0805 16.3264
050471...................................................... 24.2887 25.6172 27.1597 25.6415
050476...................................................... 23.1428 22.4754 24.0253 23.2552
050477...................................................... 27.7855 27.9595 27.5819 27.7866
050478...................................................... 23.0530 24.5401 26.3306 24.6133
050481...................................................... 26.8293 28.9722 27.7973 27.8692
050482...................................................... 16.9268 18.1217 16.0114 17.0134
050483...................................................... 21.6038 22.7182 * 22.1632
050485...................................................... 23.1933 24.1983 24.6906 24.0174
050486...................................................... 24.4967 * * 24.4967
050488...................................................... 32.8620 34.6939 31.7481 33.0979
050491...................................................... 25.1011 26.8703 27.4600 26.4606
050492...................................................... 21.4156 19.5457 20.5030 20.4277
050494...................................................... 25.4078 29.2621 29.1296 27.9125
050496...................................................... 33.0168 32.5168 34.9704 33.4862
050497...................................................... * 13.8110 15.4115 14.5264
050498...................................................... 24.8445 24.9677 26.1716 25.3085
050502...................................................... 22.6253 22.3788 25.3701 23.4214
050503...................................................... 23.5911 24.4069 23.3745 23.7879
050506...................................................... 21.2165 25.0845 25.0333 23.8164
050510...................................................... 33.4617 33.3774 33.7481 33.5309
[[Page 39964]]
050512...................................................... 34.3138 35.3581 34.4368 34.6837
050515...................................................... 35.0412 35.3419 33.7321 34.6571
050516...................................................... 25.1850 24.7992 26.1969 25.4171
050517...................................................... 20.3733 20.9550 22.0985 21.1081
050522...................................................... 31.7326 35.3784 36.2127 34.2256
050523...................................................... 28.4235 27.0544 31.2522 28.8864
050526...................................................... 26.9206 23.8099 26.4014 25.6096
050528...................................................... 18.6898 19.0611 18.9155 18.8867
050531...................................................... 20.7332 22.7308 21.3948 21.6689
050534...................................................... 23.3026 24.0700 24.0001 23.7954
050535...................................................... 24.2257 25.4215 26.8511 25.4120
050537...................................................... 22.2073 22.2256 24.0354 22.8159
050539...................................................... 23.2501 20.7129 23.3846 22.4405
050541...................................................... 34.6195 34.4573 36.6149 35.2691
050542...................................................... 17.8537 16.0892 17.7737 17.2018
050543...................................................... 23.0437 22.3994 21.6795 22.3610
050545...................................................... 27.5713 26.3304 31.7280 27.9472
050546...................................................... 27.7557 26.1949 38.8087 28.7303
050547...................................................... 27.0845 26.8305 37.7681 28.7499
050548...................................................... 26.5922 28.8083 29.8516 28.2370
050549...................................................... 27.9098 27.2765 28.9615 28.0769
050550...................................................... 25.7546 24.8048 25.6588 25.4034
050551...................................................... 24.0488 25.4652 24.8084 24.7966
050552...................................................... 22.8731 21.5216 20.3239 21.6775
050557...................................................... 22.1385 21.1243 22.2562 21.8314
050559...................................................... 24.6689 23.5759 24.7866 24.3485
050561...................................................... 33.9268 34.5791 33.4423 33.9701
050564...................................................... 24.5099 23.5922 24.2091 24.0891
050565...................................................... 22.8785 23.7829 20.8349 22.3644
050566...................................................... 18.3297 17.4423 22.3448 19.2949
050567...................................................... 24.2349 24.6454 25.0787 24.6746
050568...................................................... 20.5205 19.5816 20.5376 20.2025
050569...................................................... 24.9453 26.5479 27.3429 26.2484
050570...................................................... 24.4961 25.2294 25.8619 25.1838
050571...................................................... 24.3741 26.2039 24.0154 24.8290
050573...................................................... 25.1398 24.9644 25.6589 25.2612
050575...................................................... * 19.5611 20.7090 20.0979
050577...................................................... 20.5177 25.1549 23.5487 22.9797
050578...................................................... 28.9073 28.5379 28.9009 28.7846
050579...................................................... 30.0694 30.4952 29.9348 30.1803
050580...................................................... 23.9183 25.9004 24.6962 24.8350
050581...................................................... 23.5660 23.8584 24.9807 24.1454
050583...................................................... 23.3609 24.3987 25.8800 24.5448
050584...................................................... 23.1610 21.2366 19.5805 21.2667
050585...................................................... 26.4985 25.9426 24.2824 25.5872
050586...................................................... 23.8402 23.4079 23.1850 23.4570
050588...................................................... 30.3873 25.3094 24.5472 26.4705
050589...................................................... 24.3453 24.8698 23.8880 24.3389
050590...................................................... * 22.4480 24.4797 23.4541
050591...................................................... 22.3224 23.9412 25.0209 23.7207
050592...................................................... 26.0528 21.1745 22.1174 23.0414
050594...................................................... 22.7826 27.1584 27.7002 25.6455
050597...................................................... 23.1789 22.8523 23.3280 23.1176
050598...................................................... 28.1062 24.3597 23.9202 25.2869
050599...................................................... 26.3191 29.1221 26.0892 27.1846
050601...................................................... 32.8704 31.8670 29.7417 31.4201
050603...................................................... 22.7500 23.3390 21.7031 22.5608
050604...................................................... 33.3239 34.0461 35.4034 34.3023
050607...................................................... 24.1052 * * 24.1052
050608...................................................... 16.1529 18.0947 18.1664 17.4208
050609...................................................... 31.9340 34.9935 33.5028 33.4973
050613...................................................... 23.4779 23.3835 30.2413 25.4419
050615...................................................... 23.7015 23.8815 27.5682 24.9089
[[Page 39965]]
050616...................................................... 22.7960 22.7437 24.9843 23.5101
050618...................................................... 21.7032 21.6509 21.4895 21.6219
050623...................................................... 30.3208 29.1806 27.5832 29.0384
050624...................................................... 22.3419 22.7148 26.4659 23.7251
050625...................................................... 24.3503 26.4849 27.5816 26.1377
050630...................................................... 24.0961 23.9159 24.2120 24.0782
050633...................................................... 21.9790 23.1918 25.4283 23.5401
050635...................................................... 37.8481 * * 37.8481
050636...................................................... 20.8349 21.2618 23.5257 21.8335
050638...................................................... 23.6341 18.2859 18.2159 19.5807
050641...................................................... 21.3605 21.8315 17.1258 19.7042
050644...................................................... 23.1229 22.3456 22.1489 22.5048
050661...................................................... 20.4769 19.6780 * 20.1699
050662...................................................... 28.2910 26.9606 35.0989 28.9225
050663...................................................... 23.7097 30.6591 24.9110 25.8492
050667...................................................... 24.1064 24.9979 27.5045 25.1663
050668...................................................... 39.9001 42.0974 61.7751 44.9671
050670...................................................... 21.8750 20.0152 24.6101 21.9523
050674...................................................... 36.2361 34.7380 32.4807 34.3308
050675...................................................... 15.8423 15.6794 * 15.7602
050676...................................................... 17.5302 18.6672 20.2087 18.7455
050677...................................................... 33.7056 35.6503 33.6070 34.3198
050678...................................................... 22.6591 26.8741 22.7756 23.9129
050680...................................................... 27.3188 28.0584 31.4839 28.9200
050682...................................................... 17.9715 26.2882 17.3566 19.6443
050684...................................................... 21.8067 22.3398 23.3697 22.4849
050685...................................................... 32.1330 31.1725 35.1307 32.7762
050686...................................................... 33.2515 35.2631 33.4420 33.9679
050688...................................................... 29.9990 30.6635 31.0648 30.5922
050689...................................................... 34.1851 30.7295 30.9399 31.8127
050690...................................................... 33.8277 32.8204 34.8112 33.8469
050693...................................................... 33.2977 26.8265 25.5662 28.3155
050694...................................................... 22.5719 23.2293 23.5572 23.1120
050695...................................................... 23.5215 21.1377 24.4301 23.0784
050696...................................................... 26.4103 28.0015 28.3291 27.6235
050697...................................................... 21.4716 21.1566 18.2338 20.1433
050699...................................................... 28.4754 25.7843 17.5296 23.1610
050700...................................................... 28.4522 * * 28.4522
050701...................................................... 27.6190 22.6959 24.3055 24.7548
050702...................................................... 12.2518 * * 12.2518
050704...................................................... 20.7568 22.8716 22.7618 22.3025
050707...................................................... 27.5065 26.2732 27.8958 27.2979
050708...................................................... 21.9149 22.7821 24.8647 23.2324
050709...................................................... 19.4255 21.9598 19.4977 20.2535
050710...................................................... 26.8095 26.9060 27.5828 27.1479
050713...................................................... 15.3027 17.7259 16.8538 16.6077
050714...................................................... * 28.9314 30.1925 29.4900
050715...................................................... 19.1151 * * 19.1151
050717...................................................... * 25.9534 28.7973 27.3346
050718...................................................... * 17.6062 18.0940 17.8064
050719...................................................... * 25.5508 23.0833 23.8495
050720...................................................... * * 25.8677 25.8677
060001...................................................... 20.5908 21.3659 21.1819 21.0411
060003...................................................... 19.3243 19.8023 20.4682 19.8685
060004...................................................... 21.7899 22.8750 21.4496 22.0469
060006...................................................... 17.8613 19.3651 20.0213 19.0568
060007...................................................... 16.3833 17.4682 18.2977 17.3945
060008...................................................... 17.0944 18.0333 18.4590 17.8646
060009...................................................... 21.1795 21.4312 22.7164 21.8027
060010...................................................... 22.7241 24.0872 23.6827 23.5135
060011...................................................... 21.9727 23.4366 22.3458 22.5831
060012...................................................... 19.7746 20.1442 19.4932 19.7974
060013...................................................... 19.1369 22.7346 19.1256 20.3432
[[Page 39966]]
060014...................................................... 20.5353 24.2459 24.3210 23.0067
060015...................................................... 23.5675 20.9773 23.2469 22.5866
060016...................................................... 15.9627 16.4707 20.2408 17.3661
060018...................................................... 21.8607 20.3183 21.5083 21.2146
060020...................................................... 17.7250 18.3099 18.8985 18.3187
060022...................................................... 19.6488 21.0558 21.0830 20.6200
060023...................................................... 19.6534 19.2373 21.5475 20.1296
060024...................................................... 22.8347 21.9955 22.9185 22.5887
060027...................................................... 21.6731 20.9846 22.0713 21.5836
060028...................................................... 22.2461 23.2065 23.1792 22.8860
060029...................................................... 21.4111 20.8585 18.2938 20.0752
060030...................................................... 20.0345 20.5002 20.3452 20.2923
060031...................................................... 19.3998 21.1649 22.5067 20.9951
060032...................................................... 22.3702 23.4162 22.8123 22.8765
060033...................................................... 13.8165 15.9085 16.0760 15.2591
060034...................................................... 21.4110 22.4791 23.2816 22.4305
060036...................................................... 19.2386 15.0698 18.5988 17.4095
060037...................................................... 14.0458 15.5611 15.4513 15.0213
060038...................................................... 14.3084 14.0791 14.3249 14.2429
060041...................................................... 14.8299 14.8934 19.1263 15.9980
060042...................................................... 20.0815 19.1892 20.8597 19.9134
060043...................................................... 13.0544 13.6717 13.4443 13.3963
060044...................................................... 22.5286 19.7039 20.8673 21.1240
060046...................................................... 20.4359 19.4567 22.2699 20.7384
060047...................................................... 15.1181 15.8770 17.1534 15.9786
060049...................................................... 20.6427 21.7797 23.0613 21.7878
060050...................................................... 16.8012 18.2238 19.0832 18.0606
060052...................................................... 12.5517 13.4210 14.8729 13.6675
060053...................................................... 14.9399 15.9806 18.0232 16.2596
060054...................................................... 19.3943 22.8985 20.4160 20.8278
060056...................................................... 17.0509 18.2831 18.1263 17.9597
060057...................................................... 23.3804 26.4046 25.4185 25.1123
060058...................................................... 16.9064 15.4856 13.8539 15.6088
060060...................................................... 14.8894 15.6469 15.6018 15.4330
060062...................................................... 14.9354 17.2991 16.8640 16.3901
060063...................................................... 15.0896 * * 15.0896
060064...................................................... 20.9349 21.2207 22.7797 21.6636
060065...................................................... 24.3032 21.6305 24.5572 23.4210
060066...................................................... 14.0672 16.3485 17.2537 15.7129
060068...................................................... 19.6355 * * 19.6355
060070...................................................... 16.5821 17.3184 18.8960 17.6173
060071...................................................... 16.9545 17.5987 17.4068 17.3254
060073...................................................... 15.8385 15.7860 17.0846 16.2338
060075...................................................... 22.8498 24.1550 23.8724 23.6295
060076...................................................... 19.2861 24.8732 20.3265 21.3796
060085...................................................... 13.4761 13.6277 14.3409 13.7955
060087...................................................... 21.0277 * * 21.0277
060088...................................................... 16.6753 25.2786 13.7174 17.2655
060090...................................................... 14.5096 22.2974 16.3760 17.6196
060096...................................................... 23.1232 21.9623 20.8937 21.9261
060100...................................................... 21.9983 23.5986 23.9305 23.4279
060103...................................................... 22.3414 24.8151 23.5083 23.4950
060104...................................................... 22.3008 22.2295 21.1820 21.8472
060107...................................................... 13.6449 14.2698 21.9221 15.1674
070001...................................................... 26.5150 26.0878 26.3596 26.3266
070002...................................................... 25.4570 26.2801 26.1768 25.9680
070003...................................................... 26.0894 25.6949 27.5200 26.4175
070004...................................................... 23.2664 22.4871 24.2567 23.3158
070005...................................................... 25.5739 26.6483 26.9151 26.3676
070006...................................................... 28.7139 27.5674 28.6413 28.3103
070007...................................................... 27.1867 26.9505 26.3313 26.8152
070008...................................................... 26.0269 23.0227 24.2971 24.3585
070009...................................................... 23.4686 24.6201 24.1871 24.0886
[[Page 39967]]
070010...................................................... 25.9375 26.2354 29.2194 27.0543
070011...................................................... 23.9603 23.3638 23.0883 23.4486
070012...................................................... 25.1022 23.0321 28.8067 25.3536
070015...................................................... 25.3317 23.8240 28.1204 25.7263
070016...................................................... 26.3005 24.9148 24.4633 25.2035
070017...................................................... 24.8038 26.2923 26.0424 25.7039
070018...................................................... 28.8776 28.0689 30.6864 29.1923
070019...................................................... 24.7025 25.7283 24.9249 25.1145
070020...................................................... 23.7227 23.9987 25.9964 24.5532
070021...................................................... 26.5173 25.2978 26.3043 26.0246
070022...................................................... 25.0845 26.5691 26.9111 26.1557
070024...................................................... 25.1491 25.2983 24.8948 25.1081
070025...................................................... 25.4055 25.1315 25.4345 25.3241
070026...................................................... 18.7892 * * 18.7892
070027...................................................... 23.6381 23.6412 26.8450 24.6648
070028...................................................... 24.6913 24.6788 25.7492 25.0300
070029...................................................... 22.7507 22.0080 23.9682 22.8885
070030...................................................... 24.9676 28.9117 22.1578 25.5338
070031...................................................... 21.6565 23.4419 24.1198 23.0342
070033...................................................... 28.8099 30.4214 31.4736 30.2068
070034...................................................... 29.1220 28.9200 29.4916 29.1706
070035...................................................... 23.0574 23.0869 24.1423 23.4347
070036...................................................... 28.9463 28.8400 29.9470 29.2263
070039...................................................... 21.7791 22.9032 22.3356 22.3067
080001...................................................... 25.2849 25.4836 24.8833 25.2209
080002...................................................... 15.5984 19.6011 20.1965 18.4286
080003...................................................... 22.3957 22.1856 23.1275 22.5300
080004...................................................... 19.7725 21.9391 22.9706 21.5842
080005...................................................... 14.4289 * * 14.4289
080006...................................................... 22.2632 20.0792 22.6671 21.6173
080007...................................................... 20.3833 19.6213 21.3746 20.4985
090001...................................................... 25.8921 21.7526 21.5751 23.1400
090002...................................................... 19.6997 19.4191 21.5726 20.1912
090003...................................................... 28.6092 22.1090 23.1268 24.5792
090004...................................................... 24.4267 24.3367 25.5054 24.7042
090005...................................................... 24.8766 23.8620 26.3074 24.9846
090006...................................................... 20.0816 20.8675 22.0957 21.0167
090007...................................................... 21.6551 22.1973 29.2840 24.7855
090008...................................................... 21.5972 20.2166 25.2708 22.3042
090010...................................................... 15.8676 24.1287 23.6616 20.2595
090011...................................................... 27.3741 27.4781 26.6349 27.1495
100001...................................................... 17.6948 19.5796 20.2157 19.1458
100002...................................................... 21.3243 20.7136 21.0222 21.0141
100004...................................................... 15.2465 14.6283 15.4149 15.0845
100006...................................................... 20.6302 20.1133 21.2293 20.6802
100007...................................................... 21.7217 21.7242 22.1590 21.8790
100008...................................................... 20.7232 20.4980 20.8381 20.6876
100009...................................................... 24.2947 22.6419 22.1741 22.9648
100010...................................................... 21.9101 21.9078 23.0637 22.2904
100012...................................................... 18.5169 19.6177 20.4659 19.5030
100014...................................................... 19.8352 19.8023 19.5770 19.7276
100015...................................................... 18.2394 18.4779 18.0654 18.2696
100017...................................................... 17.7739 19.0608 19.8655 18.9086
100018...................................................... 20.8392 21.0332 21.6388 21.1816
100019...................................................... 19.8134 22.6152 23.5462 21.9719
100020...................................................... 26.1783 21.3848 20.7816 22.5004
100022...................................................... 25.8853 26.4094 26.5695 26.2778
100023...................................................... 21.1068 19.9739 19.1787 20.0604
100024...................................................... 20.7760 21.8791 22.1332 21.6047
100025...................................................... 19.1219 18.7774 19.4529 19.1169
100026...................................................... 20.7591 20.5641 20.9461 20.7639
100027...................................................... 12.9410 19.1481 14.7916 15.3484
100028...................................................... 19.7491 19.3757 19.3371 19.4791
[[Page 39968]]
100029...................................................... 19.1768 20.8745 20.8950 20.2753
100030...................................................... 18.8229 22.8204 20.5952 20.6758
100032...................................................... 19.3165 19.8127 19.7451 19.6185
100034...................................................... 18.2314 17.8743 19.5282 18.5138
100035...................................................... 19.5842 20.1540 23.8117 21.2289
100038...................................................... 24.7851 23.3578 24.5864 24.2183
100039...................................................... 20.2529 21.5297 21.7861 21.1854
100040...................................................... 18.6417 19.0449 18.6321 18.7662
100043...................................................... 17.5215 18.7993 18.8206 18.3605
100044...................................................... 21.1370 21.4764 22.7236 21.7975
100045...................................................... 20.7688 20.9216 21.0228 20.9056
100046...................................................... 21.2094 21.6207 21.3028 21.3728
100047...................................................... 18.8677 20.0114 20.6068 19.8263
100048...................................................... 13.5021 15.0584 15.7790 14.8232
100049...................................................... 18.5598 18.8535 19.1025 18.8421
100050...................................................... 16.6058 17.2377 17.9039 17.2452
100051...................................................... 18.8377 23.1273 17.9453 19.6449
100052...................................................... 16.1855 17.9537 18.1780 17.4312
100053...................................................... 18.7103 20.1724 19.6800 19.5213
100054...................................................... 18.1853 23.5491 21.1518 20.9367
100055...................................................... 17.6226 18.0547 18.8760 18.1971
100056...................................................... 23.6545 25.7863 21.8506 23.8349
100057...................................................... 18.7489 19.9712 19.5319 19.4242
100060...................................................... 22.3904 23.2561 23.5997 23.0802
100061...................................................... 21.7923 22.1133 22.9176 22.2483
100062...................................................... 17.9575 19.4370 21.4424 19.6570
100063...................................................... 16.2324 19.2629 18.4642 17.9066
100067...................................................... 17.3950 18.0877 18.4851 17.9682
100068...................................................... 18.6480 19.9305 19.8308 19.4718
100069...................................................... 16.1393 16.8271 17.3666 16.7757
100070...................................................... 20.3358 18.7408 20.0381 19.6563
100071...................................................... 16.4756 17.5451 17.7234 17.2640
100072...................................................... 19.2223 21.0225 20.5968 20.3580
100073...................................................... 18.1554 21.1898 22.2812 20.4948
100075...................................................... 18.0548 18.3688 19.4480 18.6211
100076...................................................... 16.2469 17.8733 17.8612 17.3644
100077...................................................... 19.6214 22.3438 19.0640 20.3179
100078...................................................... 18.2791 18.4499 19.2891 18.6609
100080...................................................... 21.1603 22.1966 22.7153 22.0462
100081...................................................... 13.9564 14.8313 15.4253 14.7661
100082...................................................... 19.8033 18.8998 * 19.3432
100084...................................................... 20.4002 22.3674 22.7009 21.8810
100085...................................................... 21.0802 22.1231 * 21.5986
100086...................................................... 21.1625 21.6997 23.3718 22.0734
100087...................................................... 23.1162 23.6090 23.6562 23.4609
100088...................................................... 20.0571 20.3693 20.5566 20.3435
100090...................................................... 17.8768 19.1479 19.7695 18.9939
100092...................................................... 18.1953 17.9216 20.1760 18.7907
100093...................................................... 16.6310 16.5128 16.8422 16.6633
100098...................................................... 19.0319 19.2427 20.8315 19.7124
100099...................................................... 15.2983 15.7823 15.7591 15.6112
100102...................................................... 19.3330 18.9701 19.7673 19.3542
100103...................................................... 18.1019 17.2364 18.7844 18.0201
100105...................................................... 21.5028 21.6604 21.8268 21.6611
100106...................................................... 19.3113 17.2527 17.4958 17.9164
100107...................................................... 18.0142 20.1281 20.0719 19.4041
100108...................................................... 11.4692 19.9593 20.1125 16.4375
100109...................................................... 22.1715 20.8440 20.8370 21.2360
100110...................................................... 19.6439 20.8995 20.1853 20.2509
100112...................................................... 9.7706 25.2570 15.2128 15.6728
100113...................................................... 22.2584 23.2020 21.3489 22.1642
100114...................................................... 23.4501 21.6262 22.8178 22.5825
100117...................................................... 18.8619 20.7624 20.6962 20.1889
[[Page 39969]]
100118...................................................... 19.7608 22.8702 20.7323 21.1427
100121...................................................... 19.3435 * 18.5842 18.9363
100122...................................................... 18.0551 19.8783 19.2643 19.0686
100124...................................................... 19.0527 17.0713 20.4022 18.8192
100125...................................................... 17.3358 18.9535 19.6097 18.6719
100126...................................................... 18.0943 19.5413 19.3103 18.9490
100127...................................................... 19.8727 19.9860 19.2122 19.6859
100128...................................................... 21.3653 20.1536 22.8826 21.4045
100129...................................................... 18.5723 19.1936 * 18.8646
100130...................................................... 19.1052 18.6751 20.0947 19.3019
100131...................................................... 22.1680 23.4373 23.1622 22.9338
100132...................................................... 16.8978 18.1167 18.7863 17.9218
100134...................................................... 13.4711 15.1764 15.9733 14.8260
100135...................................................... 17.4785 18.8253 19.1865 18.5050
100137...................................................... 19.0464 18.6955 19.5562 19.1372
100138...................................................... 11.0135 17.1373 14.9539 13.7935
100139...................................................... 15.6444 15.6514 15.2532 15.5227
100140...................................................... 17.3518 17.1389 19.0584 17.8826
100142...................................................... 18.6812 19.6815 18.4113 18.9199
100144...................................................... 15.0197 12.2877 * 13.4059
100145...................................................... 19.1143 * * 19.1143
100146...................................................... 17.8692 18.1267 21.3359 19.1001
100147...................................................... 14.6751 14.6616 15.2348 14.8665
100150...................................................... 21.0224 21.2807 21.5057 21.2659
100151...................................................... 19.3990 21.6087 23.8489 21.6478
100154...................................................... 19.8485 20.0015 20.4068 20.1020
100156...................................................... 17.1335 19.4980 18.4779 18.3856
100157...................................................... 21.0324 22.6744 22.6195 22.1032
100159...................................................... 16.3778 10.2793 10.7818 11.9429
100160...................................................... 21.6339 20.5581 23.3121 21.8278
100161...................................................... 21.5025 22.2994 22.3053 22.0508
100162...................................................... 19.8748 20.1411 20.3110 20.1117
100165...................................................... 18.5739 19.0388 22.6622 20.3299
100166...................................................... 20.4228 20.0250 21.2309 20.5491
100167...................................................... 21.8138 23.4075 23.2969 22.8605
100168...................................................... 20.1260 20.1994 20.3167 20.2165
100169...................................................... 20.7778 20.9506 20.3017 20.6703
100170...................................................... 15.1167 18.5088 19.3005 17.5325
100172...................................................... 15.1848 14.3446 14.8826 14.8099
100173...................................................... 17.3416 18.5662 17.1337 17.6572
100174...................................................... 20.5125 26.1826 21.9807 22.2819
100175...................................................... 17.8237 18.1692 20.5442 19.0035
100176...................................................... 24.6978 22.8604 24.3089 23.9493
100177...................................................... 22.0034 24.4296 24.4284 23.5639
100179...................................................... 20.9053 22.3015 23.0849 22.0467
100180...................................................... 18.4754 20.2130 21.5388 20.0049
100181...................................................... 24.5704 23.0800 18.9510 21.8206
100183...................................................... 20.8579 24.6121 23.0654 22.6623
100187...................................................... 20.6938 20.2533 20.8535 20.6013
100189...................................................... 21.0102 21.3147 26.5962 23.0255
100191...................................................... 18.4692 19.9879 21.0647 19.7731
100199...................................................... 23.3713 21.7193 * 22.5030
100200...................................................... 22.2575 22.4579 23.8729 22.8861
100203...................................................... 18.8628 * * 18.8628
100204...................................................... 20.2049 20.8995 20.2193 20.4418
100206...................................................... 20.3511 19.5710 20.1171 20.0138
100207...................................................... 15.9173 * * 15.9173
100208...................................................... 20.8337 21.2117 20.7029 20.9220
100209...................................................... 19.7329 22.4577 23.3903 21.8570
100210...................................................... 19.1799 21.3575 21.8545 20.7662
100211...................................................... 25.5277 20.6427 20.7516 21.9172
100212...................................................... 25.3441 21.1187 21.1263 22.2176
100213...................................................... 19.1238 20.6558 21.1818 20.2975
[[Page 39970]]
100217...................................................... 19.8700 20.5909 22.7335 21.0211
100220...................................................... 19.9121 21.2796 21.8246 20.9627
100221...................................................... 22.2517 17.3965 21.2321 20.0812
100222...................................................... 22.1958 * * 22.1958
100223...................................................... 18.7580 20.6302 20.2233 19.8755
100224...................................................... 24.7023 20.0251 21.8628 21.8826
100225...................................................... 20.6404 20.6802 21.5059 20.9335
100226...................................................... 24.8641 20.6858 21.8808 22.2342
100228...................................................... 23.6986 21.3168 20.8810 21.8300
100229...................................................... 18.2070 19.6908 18.2350 18.7682
100230...................................................... 20.6018 20.5051 22.5650 21.2357
100231...................................................... 17.4002 17.9226 18.7526 18.0268
100232...................................................... 17.3171 19.3491 19.8002 18.8267
100234...................................................... 21.5763 20.9104 21.6360 21.3290
100235...................................................... 17.6648 17.1622 * 17.4262
100236...................................................... 21.8111 20.3766 20.6942 20.8937
100237...................................................... 22.9344 22.0865 23.2408 22.7368
100238...................................................... 17.6310 19.6367 20.8252 19.4032
100239...................................................... 19.7605 21.3193 19.4481 20.1474
100240...................................................... 17.9339 20.4340 21.0606 19.8014
100241...................................................... 13.8344 14.7224 17.1063 15.0865
100242...................................................... 17.1154 17.9260 18.6938 17.9097
100243...................................................... 20.3838 21.2644 20.8041 20.8228
100244...................................................... 17.4124 18.6227 20.5352 18.9148
100246...................................................... 21.2160 19.6376 21.9247 20.8876
100248...................................................... 21.5399 20.7007 21.2988 21.1681
100249...................................................... 19.0243 19.2808 18.1397 18.8067
100252...................................................... 17.8726 17.7778 19.8079 18.4729
100253...................................................... 20.6014 21.3232 22.4778 21.5023
100254...................................................... 20.9080 19.6598 19.5523 19.9896
100255...................................................... 21.0224 25.2119 21.0284 22.2338
100256...................................................... 23.5640 20.9356 21.2786 21.7690
100258...................................................... 21.8764 21.3501 20.0300 21.0257
100259...................................................... 19.8600 20.3815 21.1160 20.4723
100260...................................................... 21.2224 21.0506 24.9183 22.3504
100262...................................................... 19.5874 20.0433 21.0927 20.2558
100263...................................................... 16.9012 * * 16.9012
100264...................................................... 17.6085 19.1556 19.9491 18.8967
100265...................................................... 19.8571 18.8301 18.2291 18.8491
100266...................................................... 17.7319 18.2993 19.3623 18.4763
100267...................................................... 17.0986 20.1141 21.7430 19.6266
100268...................................................... 23.5863 23.9249 24.0538 23.8633
100269...................................................... 21.2047 21.6724 22.5114 21.8200
100270...................................................... 19.8576 15.1462 16.7148 17.2012
100271...................................................... 19.9208 20.4824 20.8695 20.4494
100275...................................................... 21.3273 20.9188 21.4904 21.2374
100276...................................................... 21.9797 22.3646 24.1022 22.8308
100277...................................................... 16.1410 16.6255 19.7241 17.0041
100279...................................................... 23.0213 22.9095 22.5879 22.8402
100280...................................................... 16.5851 17.3676 18.1972 17.4129
100281...................................................... 22.0202 22.4392 23.0142 22.5262
100282...................................................... 19.7717 19.1978 18.4884 19.1653
100284...................................................... * * 18.9448 18.9448
110001...................................................... 18.0571 19.1971 20.1150 19.1086
110002...................................................... 17.3674 17.1406 19.5158 18.0122
110003...................................................... 16.9099 18.1168 17.1450 17.3940
110004...................................................... 18.9468 19.5591 19.7733 19.4194
110005...................................................... 19.2639 17.7348 22.4568 20.0888
110006...................................................... 20.1273 20.7820 21.0601 20.6571
110007...................................................... 23.4976 21.9505 25.2523 23.5682
110008...................................................... 18.2642 22.0081 18.5265 19.5622
110009...................................................... 14.8218 16.3069 17.4306 16.2843
110010...................................................... 24.5493 23.3213 23.9104 23.9180
[[Page 39971]]
110011...................................................... 18.2846 18.6144 18.9823 18.6368
110013...................................................... 16.0264 16.2811 18.9160 17.1183
110014...................................................... 16.1168 16.0658 18.1787 16.7192
110015...................................................... 19.4769 21.2146 20.9926 20.5614
110016...................................................... 15.2967 22.5321 14.2398 16.6540
110017...................................................... 10.5399 13.1960 22.2537 15.3899
110018...................................................... 21.0415 19.6064 22.1480 20.9298
110020...................................................... 18.5251 18.3147 19.4617 18.7736
110023...................................................... 18.6460 21.1994 22.0546 20.5885
110024...................................................... 19.7923 20.7297 20.7345 20.4144
110025...................................................... 18.6463 19.5749 20.4232 19.5033
110026...................................................... 16.1414 17.2977 16.2484 16.5517
110027...................................................... 14.6834 16.0642 14.7081 15.1696
110028...................................................... 19.8894 20.1547 29.1670 22.3800
110029...................................................... 20.0507 20.2906 21.2150 20.5454
110030...................................................... 17.6785 18.8105 19.6412 18.7203
110031...................................................... 21.5794 19.9482 20.0553 20.4598
110032...................................................... 16.1859 15.7349 18.2014 16.6413
110033...................................................... 21.4143 22.1879 25.6335 22.9577
110034...................................................... 18.1882 19.6055 19.5554 19.0987
110035...................................................... 21.1670 19.3795 22.7950 21.1658
110036...................................................... 24.4181 22.2498 20.7284 22.3301
110038...................................................... 16.3750 17.7060 17.7396 17.2680
110039...................................................... 20.7710 20.6011 20.4998 20.6248
110040...................................................... 16.4043 17.0743 16.8083 16.7529
110041...................................................... 16.6927 18.8035 20.2755 18.6583
110042...................................................... 20.6503 24.0153 25.2331 23.2575
110043...................................................... 17.2175 20.1016 20.6150 19.2219
110044...................................................... 19.5983 16.3624 17.2087 17.5794
110045...................................................... 19.9445 20.2498 21.3049 20.4714
110046...................................................... 19.2327 19.7377 21.4905 20.1167
110048...................................................... 15.6463 16.3148 15.6113 15.8483
110049...................................................... 14.2135 16.1817 16.8639 15.7669
110050...................................................... 18.7516 20.7619 19.2291 19.5578
110051...................................................... 15.7475 17.0070 17.2292 16.6496
110052...................................................... 15.0562 * * 15.0562
110054...................................................... 19.2712 * 20.0549 19.6625
110056...................................................... 16.4960 15.6202 17.7959 16.7305
110059...................................................... 17.6984 16.6678 16.7990 17.0253
110061...................................................... 13.7196 15.0367 16.3557 15.0889
110062...................................................... 12.2107 18.8019 17.0053 16.1264
110063...................................................... 17.9743 16.9612 18.5071 17.7965
110064...................................................... 18.3368 18.9515 19.1203 18.8163
110065...................................................... 13.3245 15.6771 16.3546 15.1604
110066...................................................... 20.6502 21.0207 22.4189 21.3274
110069...................................................... 18.3519 19.3109 20.9575 19.5384
110070...................................................... 18.2264 21.0227 17.3438 18.7743
110071...................................................... 14.8902 14.5984 18.8321 15.8863
110072...................................................... 12.4303 12.7877 12.7625 12.6652
110073...................................................... 15.1377 15.4261 16.4658 15.6663
110074...................................................... 20.7572 21.3945 22.3769 21.5169
110075...................................................... 17.0067 18.5199 20.1757 18.5793
110076...................................................... 20.4430 21.2867 21.9798 21.2384
110078...................................................... 24.7069 22.3718 24.0893 23.6954
110079...................................................... 20.1385 21.0593 22.1070 21.0913
110080...................................................... 23.4336 18.4768 19.1839 20.1449
110082...................................................... 22.0078 23.8768 24.3140 23.4175
110083...................................................... 21.3578 23.1219 23.1463 22.5746
110086...................................................... 14.9756 18.2815 16.6374 16.5417
110087...................................................... 20.5420 21.7773 22.7069 21.7189
110089...................................................... 18.5761 18.5587 19.3855 18.8318
110091...................................................... 21.3789 19.5114 21.5328 20.7784
110092...................................................... 15.0890 17.3479 16.9725 16.4433
[[Page 39972]]
110093...................................................... 14.8049 * 16.9827 15.7486
110094...................................................... 13.8658 14.5641 16.9503 15.0650
110095...................................................... 15.9478 16.4670 17.1195 16.5075
110096...................................................... 16.3202 16.8541 17.4157 16.8647
110097...................................................... 15.6164 15.5811 17.4558 16.1121
110098...................................................... 14.0067 16.3532 16.0597 15.3226
110100...................................................... 20.3764 18.6978 19.0764 19.3213
110101...................................................... 11.7278 10.8187 18.8491 12.7872
110103...................................................... 11.9352 13.6842 21.1837 14.0859
110104...................................................... 15.3184 15.7781 15.9431 15.6829
110105...................................................... 16.5196 16.8909 16.7775 16.7306
110107...................................................... 17.3921 19.3609 19.3897 18.7335
110108...................................................... 15.1401 19.7938 25.2161 19.3940
110109...................................................... 16.3703 15.9359 16.4031 16.2270
110111...................................................... 17.3215 18.5108 18.3951 18.0800
110112...................................................... 19.1288 19.0619 19.8986 19.3117
110113...................................................... 15.1896 16.8179 15.9532 15.9721
110114...................................................... 15.1303 14.6888 16.4812 15.4358
110115...................................................... 24.8332 43.9427 22.5049 27.8401
110118...................................................... 15.3992 20.5368 19.7509 18.5122
110120...................................................... 15.1878 15.2589 17.7452 15.9897
110121...................................................... 15.5792 16.2711 19.3643 17.0685
110122...................................................... 18.8497 21.1385 21.1469 20.3688
110124...................................................... 17.1306 17.5732 18.3366 17.6460
110125...................................................... 17.3254 19.1311 18.0090 18.1411
110127...................................................... 13.7612 14.6143 20.3765 16.2641
110128...................................................... 18.9705 18.1845 18.0835 18.4293
110129...................................................... 18.1208 18.9388 19.0001 18.6851
110130...................................................... 13.0779 16.0580 14.6011 14.6559
110132...................................................... 15.0231 16.0419 16.3943 15.8158
110134...................................................... 11.5583 12.5723 19.8639 15.1252
110135...................................................... 17.0834 17.4380 17.3504 17.2967
110136...................................................... 16.1680 18.0639 16.9629 16.8702
110140...................................................... 17.8806 17.8870 17.7915 17.8571
110141...................................................... 12.5051 13.2501 14.4935 13.4024
110142...................................................... 12.3029 14.6144 13.9525 13.5947
110143...................................................... 21.6898 20.1603 22.5926 21.5352
110144...................................................... 17.9766 16.8685 17.5112 17.4397
110146...................................................... 17.6068 16.1316 17.1835 16.9320
110149...................................................... 22.2256 17.7535 32.1975 23.0615
110150...................................................... 18.7724 20.2644 21.2909 20.0962
110152...................................................... 14.7674 15.3996 15.1324 15.1011
110153...................................................... 18.6862 19.2744 20.5068 19.4781
110154...................................................... 14.8067 14.9636 17.3761 15.6408
110155...................................................... 17.1370 15.5306 16.5146 16.3434
110156...................................................... 15.3422 14.7477 16.3876 15.4698
110161...................................................... 20.8657 21.7153 22.2861 21.6563
110163...................................................... 18.2016 20.4202 18.6637 19.0060
110164...................................................... 19.4946 20.2074 21.2160 20.2947
110165...................................................... 18.9974 21.2577 20.8030 20.3401
110166...................................................... 19.8510 20.5882 20.5049 20.3148
110168...................................................... 19.8178 20.6646 21.8058 20.8014
110169...................................................... 18.7189 20.6385 22.6648 20.4216
110171...................................................... 20.0874 23.7893 25.5296 22.6284
110172...................................................... 25.4390 23.3730 23.6803 24.1715
110174...................................................... 14.2978 13.7339 14.6199 14.1905
110176...................................................... 22.3971 * * 22.3971
110177...................................................... 19.5888 20.7187 21.2796 20.5272
110178...................................................... 16.8555 18.8306 * 17.8083
110179...................................................... 20.5161 22.7841 22.0767 21.7231
110181...................................................... 13.7195 14.0941 12.9798 13.6399
110183...................................................... 21.1797 23.3826 22.5148 22.3473
110184...................................................... 20.9465 22.1970 22.1920 21.7791
[[Page 39973]]
110185...................................................... 16.2487 16.7246 17.7925 16.9013
110186...................................................... 17.3398 17.4287 18.3178 17.6984
110187...................................................... 21.4462 20.1154 19.8419 20.4516
110188...................................................... 20.0548 24.8376 23.7032 22.6465
110189...................................................... 18.8627 22.2715 20.8786 20.7023
110190...................................................... 19.4318 18.5728 18.3649 18.7761
110191...................................................... 19.1065 20.2033 21.4033 20.2583
110192...................................................... 20.7660 21.4951 21.0486 21.1064
110193...................................................... 18.7807 20.6380 20.7867 20.0518
110194...................................................... 15.0937 15.1480 14.8115 15.0165
110195...................................................... 10.5227 13.9135 12.7261 12.3146
110198...................................................... 26.1898 24.1999 24.8646 25.0493
110200...................................................... 17.2129 18.1862 17.7744 17.7301
110201...................................................... 19.2438 20.4699 20.9497 20.2248
110203...................................................... 20.2958 26.8148 22.7453 23.1944
110204...................................................... 20.5728 19.7317 30.7342 21.7754
110205...................................................... 26.1154 21.1435 21.3617 22.7145
110207...................................................... 12.8710 12.9727 14.7154 13.5335
110208...................................................... 14.8907 15.1742 15.6161 5.1789
110209...................................................... 20.4640 17.9190 18.6404 18.9942
110211...................................................... 21.8226 20.9372 26.9151 23.1427
110212...................................................... 12.6583 11.8545 14.3790 12.8830
110213...................................................... 13.1976 14.3651 * 13.7453
110215...................................................... * 20.1928 18.1539 19.0047
110216...................................................... * * 27.1878 27.1878
120001...................................................... 26.7134 27.9213 29.0427 27.8237
120002...................................................... 24.3780 25.0744 25.2021 24.8896
120003...................................................... 23.8452 25.9059 23.9115 24.5394
120004...................................................... 24.0456 23.9208 24.8632 24.2413
120005...................................................... 20.5380 23.3975 24.1662 22.6197
120006...................................................... 23.7151 25.0895 25.8943 24.8700
120007...................................................... 23.2684 22.7200 22.8772 22.9509
120009...................................................... 19.0216 17.4693 16.4485 17.5600
120010...................................................... 25.3976 25.1480 24.1923 24.8868
120011...................................................... 33.5459 35.0582 37.2759 35.3313
120012...................................................... 22.5219 23.1144 21.8507 22.5391
120014...................................................... 24.0467 22.8866 24.1208 23.6739
120015...................................................... 29.0747 32.9906 42.6465 33.1800
120016...................................................... 29.4104 27.9127 45.1899 31.1230
120018...................................................... 25.6088 24.5031 31.1879 26.2841
120019...................................................... 21.9199 22.9341 25.5659 23.4285
120021...................................................... 19.4236 23.4508 23.1839 21.8865
120022...................................................... 17.9306 21.7868 19.2614 19.5032
120024...................................................... 22.2846 29.4808 32.2514 26.8486
120025...................................................... 19.0197 20.1065 50.6376 21.3455
120026...................................................... 23.2237 26.0787 25.1314 24.7719
120027...................................................... 24.5549 24.7255 24.4535 24.5737
120028...................................................... 23.4873 27.5023 27.0897 25.8902
130001...................................................... 24.9511 18.8471 17.6306 20.1752
130002...................................................... 16.1853 16.6620 16.9867 16.6200
130003...................................................... 19.9499 21.7313 22.3430 21.3583
130005...................................................... 20.1678 20.7169 21.2386 20.7149
130006...................................................... 18.8705 19.3392 20.4614 19.5797
130007...................................................... 19.8442 20.8338 21.8107 20.8426
130008...................................................... 12.9177 12.5506 13.6018 12.9892
130009...................................................... 18.2958 19.1837 15.9701 17.7296
130010...................................................... 21.4325 17.6795 17.5119 18.7875
130011...................................................... 19.0816 20.5031 20.1147 19.9190
130012...................................................... 22.6153 22.9813 24.9976 23.5891
130013...................................................... 19.2170 17.4038 15.1129 17.1523
130014...................................................... 17.9836 18.9769 19.2107 18.7286
130015...................................................... 15.2662 15.7233 18.5913 16.3849
130016...................................................... 16.9987 17.3942 19.0516 17.7864
[[Page 39974]]
130017...................................................... 16.8822 17.1710 19.6875 17.7220
130018...................................................... 17.9651 19.7368 19.8425 19.2288
130019...................................................... 17.2317 18.6648 19.1711 18.3322
130021...................................................... 12.2562 12.8588 15.6155 13.6528
130022...................................................... 19.5040 16.5270 18.9127 18.2241
130024...................................................... 18.3789 19.3634 19.0703 18.9600
130025...................................................... 15.2691 17.5213 16.4627 16.4881
130026...................................................... 20.5535 21.5934 21.8106 21.3093
130027...................................................... 20.7044 21.4279 20.5344 20.8883
130028...................................................... 18.2074 19.1093 20.9674 19.4388
130029...................................................... 20.3153 18.4263 18.7694 19.1364
130030...................................................... 18.3981 17.8440 17.5759 17.9347
130031...................................................... 17.6458 16.2397 16.7766 16.8967
130034...................................................... 18.8164 16.9873 18.9483 18.2785
130035...................................................... 20.4708 19.3478 20.7770 20.1943
130036...................................................... 13.7942 13.7933 13.6362 13.7373
130037...................................................... 17.7374 18.8071 18.6856 18.3986
130043...................................................... 16.0686 16.5102 16.7904 16.4511
130044...................................................... 13.1816 17.8160 13.4513 14.6424
130045...................................................... 16.4655 16.0990 19.0208 17.0869
130048...................................................... 15.0924 16.0899 16.7900 15.9311
130049...................................................... 20.3928 20.3129 22.4440 21.0760
130054...................................................... 17.7802 17.2729 17.7085 17.5766
130056...................................................... 15.6551 14.6862 20.9476 16.5492
130058...................................................... 17.7462 * * 17.7462
130060...................................................... 20.8508 21.8662 22.7399 21.8288
130061...................................................... 16.7839 15.4006 14.7394 15.6929
130062...................................................... 15.1086 16.5672 19.8157 17.1915
130063...................................................... * 15.9441 18.8024 17.8420
140001...................................................... 15.4448 16.3372 17.7990 16.4814
140002...................................................... 19.2575 19.0248 19.9284 19.3999
140003...................................................... 18.0001 21.2886 17.8595 18.9466
140004...................................................... 17.5200 15.7042 17.4574 16.8965
140005...................................................... 10.8718 11.6127 12.3002 11.5858
140007...................................................... 22.4015 22.9799 23.8585 23.0838
140008...................................................... 21.2844 21.6548 22.1111 21.6838
140010...................................................... 25.2227 31.8207 28.5635 28.3677
140011...................................................... 17.2856 17.8676 18.6164 17.9499
140012...................................................... 19.4406 23.0653 21.4374 21.2652
140013...................................................... 17.3488 18.3060 19.6722 18.4213
140014...................................................... 20.7563 22.4737 21.4042 21.5054
140015...................................................... 15.0232 16.6735 17.6805 16.4314
140016...................................................... 12.5363 13.1278 14.4938 13.3972
140018...................................................... 21.4147 22.3070 22.4132 22.0345
140019...................................................... 15.3435 16.6548 16.4254 16.1654
140024...................................................... 14.6674 16.8271 15.3782 15.5912
140025...................................................... 16.9489 16.9462 18.5135 17.4713
140026...................................................... 15.9557 16.6612 18.3220 16.9446
140027...................................................... 17.5023 18.7553 19.2149 18.5013
140029...................................................... 21.0358 22.8322 26.0833 23.2140
140030...................................................... 22.4414 21.9475 23.1760 22.5308
140031...................................................... 15.9442 19.5731 17.6067 17.6942
140032...................................................... 17.3363 18.1058 19.0383 18.1645
140033...................................................... 22.5583 24.1722 25.1639 23.9291
140034...................................................... 19.1482 19.5278 19.8792 19.5183
140035...................................................... 12.9963 15.2649 15.5040 14.5633
140036...................................................... 17.0419 18.5771 19.1076 18.2935
140037...................................................... 12.5012 13.0764 14.1083 13.2105
140038...................................................... 17.6094 18.3035 18.4948 18.1352
140040...................................................... 16.2462 19.9267 16.7450 17.5895
140041...................................................... 17.2829 17.6582 18.5952 17.8248
140042...................................................... 15.6092 15.4095 15.8892 15.6354
140043...................................................... 18.9464 19.4683 20.1176 19.5022
[[Page 39975]]
140045...................................................... 20.6541 15.5807 17.7799 17.9528
140046...................................................... 16.4621 18.9763 18.6371 18.0097
140047...................................................... 16.3298 17.1539 13.3610 15.4382
140048...................................................... 20.5773 24.0913 23.9545 22.8943
140049...................................................... 21.5937 28.4958 26.9483 25.7338
140051...................................................... 20.8455 23.8264 24.0796 22.8956
140052...................................................... 19.6045 19.6409 17.9571 19.0338
140053...................................................... 17.8218 19.1892 19.9620 18.9702
140054...................................................... 26.1497 22.1921 23.1576 23.7695
140055...................................................... 14.8031 16.3404 14.3603 15.1391
140058...................................................... 17.2716 17.4927 18.6861 17.8100
140059...................................................... 15.3934 15.0195 * 15.1978
140061...................................................... 15.9612 17.3012 18.2039 17.1185
140062...................................................... 27.0912 28.0877 28.5304 27.9131
140063...................................................... 22.3882 25.3641 29.1453 25.1919
140064...................................................... 19.2549 19.1023 18.9379 19.0960
140065...................................................... 23.1610 24.1128 25.3336 24.1516
140066...................................................... 16.1759 17.3902 13.6491 15.5770
140067...................................................... 18.4031 19.3267 19.5292 19.0846
140068...................................................... 18.8739 19.9691 21.6188 20.0995
140069...................................................... 16.1453 16.7544 17.3879 16.7949
140070...................................................... 19.2995 22.9678 22.7153 21.2244
140074...................................................... 19.0077 19.3504 21.6052 19.9120
140075...................................................... 22.5083 21.6313 21.6434 21.9439
140077...................................................... 16.6447 17.5305 17.3647 17.1709
140079...................................................... 21.9205 23.3020 23.6928 22.9153
140080...................................................... 20.9999 21.0739 22.1968 21.3875
140081...................................................... 15.5103 16.2247 16.9808 16.1897
140082...................................................... 22.6227 23.8960 29.7262 24.9037
140083...................................................... 18.1349 19.3145 21.0330 19.4951
140084...................................................... 20.0133 20.9709 22.3467 21.0939
140086...................................................... 17.3717 18.3803 19.1613 18.3356
140087...................................................... 18.3639 16.1009 17.1147 17.1839
140088...................................................... 24.2568 25.2369 25.4176 24.9650
140089...................................................... 17.2086 17.6366 18.3157 17.7164
140090...................................................... 23.5888 26.4325 26.9364 25.3709
140091...................................................... 20.7039 20.9018 21.9322 21.1441
140093...................................................... 19.1469 18.2899 20.1528 19.1437
140094...................................................... 20.6129 21.4709 21.9383 21.3227
140095...................................................... 21.5376 24.0549 24.2859 23.1400
140097...................................................... 16.8997 17.5081 21.1719 18.4160
140100...................................................... 19.0588 21.3581 23.1399 21.1571
140101...................................................... 26.0894 21.5473 21.4211 22.7744
140102...................................................... 15.0777 17.1500 17.5729 16.5644
140103...................................................... 17.8586 19.2783 18.1303 18.4145
140105...................................................... 20.9068 22.6573 22.8944 22.1275
140107...................................................... 12.7573 13.7533 11.8383 12.6800
140108...................................................... 28.6028 25.4742 26.9971 26.9964
140109...................................................... 15.4724 15.7465 14.5498 15.2467
140110...................................................... 18.8112 19.1822 19.2888 19.0728
140112...................................................... 16.2399 17.6856 17.6974 17.1885
140113...................................................... 17.9151 19.0592 19.5584 18.8265
140114...................................................... 20.4808 21.1639 21.0976 20.9149
140115...................................................... 20.0939 21.1926 21.0433 20.7564
140116...................................................... 21.8290 23.1177 23.8993 22.9520
140117...................................................... 19.6445 21.5671 21.4876 20.8750
140118...................................................... 23.0797 23.5952 24.3260 23.6559
140119...................................................... 26.5042 29.1419 27.9145 27.8197
140120...................................................... 14.8375 18.0743 17.9716 16.8874
140121...................................................... 9.5268 16.0397 16.6993 13.2257
140122...................................................... 23.7473 24.6470 26.1270 24.8110
140124...................................................... 26.9706 27.1906 27.9813 27.3549
140125...................................................... 17.0974 17.6759 16.9516 17.2453
[[Page 39976]]
140127...................................................... 19.4259 19.8973 20.0489 19.7765
140128...................................................... 17.6751 19.4955 23.1327 20.0664
140129...................................................... 15.2494 18.2639 20.2868 17.8627
140130...................................................... 23.7682 22.2285 23.4298 23.1296
140132...................................................... 23.0443 23.5475 23.3054 23.2992
140133...................................................... 19.9083 21.4090 21.4166 20.8761
140135...................................................... 17.6927 17.8100 17.3985 17.6268
140137...................................................... 16.5141 16.8969 18.6330 17.3470
140138...................................................... 14.5877 16.7420 17.1968 16.2121
140139...................................................... 16.5794 14.0619 11.0397 13.5138
140140...................................................... 15.2985 17.8243 17.6845 16.9747
140141...................................................... 15.1782 17.5204 19.1097 17.2133
140143...................................................... 18.7616 19.1862 19.0810 19.0186
140144...................................................... 19.7913 21.3245 22.2864 21.1022
140145...................................................... 16.6111 17.5471 18.1788 17.4556
140146...................................................... 23.7400 21.9573 19.9704 21.7285
140147...................................................... 24.8191 16.1336 18.8049 19.2135
140148...................................................... 19.5026 18.6598 18.7730 18.9637
140150...................................................... 27.8485 27.3378 24.7976 26.6536
140151...................................................... 19.3016 21.3896 20.0310 20.2086
140152...................................................... 22.4270 24.6333 25.6011 24.1041
140155...................................................... 17.3131 19.9738 20.2778 19.1103
140158...................................................... 22.2666 22.7639 22.7988 22.5990
140160...................................................... 17.8822 17.7691 17.7921 17.8132
140161...................................................... 19.0448 20.0948 20.3799 19.8258
140162...................................................... 18.4167 19.6464 20.3452 19.4479
140164...................................................... 18.6120 18.7806 18.6589 18.6860
140165...................................................... 15.4186 14.9156 14.7223 15.0080
140166...................................................... 17.5434 17.5496 18.3833 17.8149
140167...................................................... 16.5671 17.1479 17.6525 17.1325
140168...................................................... 16.4638 16.6770 17.7453 16.9752
140170...................................................... 14.1360 16.1621 16.4107 15.5211
140171...................................................... 14.7316 14.1637 15.0237 14.6354
140172...................................................... 20.7982 23.8431 23.6262 22.5610
140173...................................................... 18.4788 15.1487 16.3924 16.7054
140174...................................................... 19.9216 20.5339 35.9320 23.2157
140176...................................................... 21.4129 23.2866 24.5338 23.0397
140177...................................................... 18.1692 18.2648 15.0827 17.1204
140179...................................................... 22.6989 21.1948 21.9859 21.9622
140180...................................................... 23.2536 22.4548 22.7996 22.8262
140181...................................................... 20.5461 20.8709 21.9864 21.1001
140182...................................................... 20.7013 22.0170 28.9515 23.2649
140184...................................................... 14.9763 17.8155 17.2401 16.6194
140185...................................................... 17.3616 17.6514 18.2867 17.7696
140186...................................................... 18.9878 22.7890 23.5034 21.7241
140187...................................................... 17.6910 17.9201 18.3331 17.9863
140188...................................................... 14.8373 15.2479 16.1907 15.4001
140189...................................................... 19.0791 21.0616 20.6627 20.2758
140190...................................................... 15.8770 16.3366 17.5263 16.5534
140191...................................................... 24.7368 25.8835 25.2628 25.2833
140193...................................................... 15.5196 15.8022 17.4057 16.2409
140197...................................................... 17.9828 18.6394 19.3774 18.6752
140199...................................................... 18.8333 18.3507 18.0450 18.4044
140200...................................................... 21.6508 21.5220 21.7680 21.6496
140202...................................................... 22.1800 22.1939 23.7955 22.7597
140203...................................................... 20.7854 19.9194 21.0848 20.5915
140205...................................................... 17.2369 17.4751 20.0784 18.0505
140206...................................................... 20.5096 21.3295 22.5109 21.4570
140207...................................................... 20.2048 21.9779 22.3905 21.3996
140208...................................................... 23.9441 25.9900 26.2527 25.3856
140209...................................................... 17.7889 18.1206 20.1557 18.6405
140210...................................................... 12.6648 15.6899 14.8248 14.4319
140211...................................................... 20.9615 21.8891 22.6265 21.8594
[[Page 39977]]
140213...................................................... 26.2041 27.0645 24.9892 26.0871
140215...................................................... 14.4544 15.9949 15.2893 15.2456
140217...................................................... 23.3192 24.8229 25.7329 24.5914
140218...................................................... 15.0750 14.9459 14.9851 15.0038
140220...................................................... 16.7341 17.6370 17.8450 17.4280
140223...................................................... 21.4725 24.9249 24.9017 23.6377
140224...................................................... 22.9945 25.8668 32.8292 26.7133
140228...................................................... 18.6731 19.6988 20.1688 19.5400
140230...................................................... 16.5979 18.0918 18.2983 17.6740
140231...................................................... 21.6062 23.9176 24.5019 23.4404
140233...................................................... 18.3703 19.4542 21.2333 19.6539
140234...................................................... 18.7156 18.9945 * 18.8552
140236...................................................... 13.1341 * 12.9253 13.0112
140239...................................................... 18.8785 18.8127 20.3745 19.3689
140240...................................................... 24.2141 23.6860 24.6949 24.1989
140242...................................................... 22.6679 24.5428 25.2317 24.1792
140245...................................................... 15.5554 13.4839 14.2481 14.3597
140246...................................................... 12.8238 13.4639 11.6267 12.5798
140250...................................................... 23.4127 25.0876 23.6449 24.0578
140251...................................................... 20.5813 21.4385 21.9435 21.3153
140252...................................................... 24.4856 25.2246 25.0220 24.9139
140253...................................................... 16.7356 18.5511 19.5858 18.2440
140258...................................................... 21.1321 23.2973 25.3622 23.2691
140271...................................................... 15.3606 15.5079 12.0079 14.1590
140275...................................................... 17.9597 20.1699 23.8171 20.5857
140276...................................................... 23.7163 26.6777 25.3134 25.2323
140280...................................................... 18.8420 20.2360 18.8300 19.2649
140281...................................................... 23.3433 24.0192 25.2719 24.2302
140285...................................................... 14.7087 18.1181 18.5916 17.2227
140286...................................................... 19.9500 20.3735 26.1290 22.0885
140288...................................................... 21.8213 25.2327 24.4331 23.7989
140289...................................................... 16.4542 17.1388 18.1747 17.3055
140290...................................................... 21.2384 21.1784 22.8590 21.7763
140291...................................................... 22.4352 25.0911 24.9537 24.1790
140292...................................................... 22.7136 20.8560 21.9950 21.8371
140294...................................................... 17.5226 17.7226 17.7301 17.6645
140297...................................................... 21.4692 * * 21.4692
140300...................................................... 23.2560 25.3662 27.8436 25.5898
150001...................................................... 21.6990 22.8109 24.0620 22.8643
150002...................................................... 18.7568 19.3401 20.7651 19.6416
150003...................................................... 19.3117 19.7661 20.8636 19.9824
150004...................................................... 19.7020 20.3685 21.2449 20.4349
150005...................................................... 18.9964 20.6260 21.6806 20.4380
150006...................................................... 20.0433 20.8158 20.6523 20.5130
150007...................................................... 19.5255 20.1826 20.6635 20.1487
150008...................................................... 20.9684 21.4545 21.8457 21.4285
150009...................................................... 18.2168 18.7073 19.0030 18.6289
150010...................................................... 18.4776 21.7125 20.5570 20.1836
150011...................................................... 19.1957 18.3742 18.3275 18.6280
150012...................................................... 20.5193 22.4751 22.1402 21.6785
150013...................................................... 16.0043 17.0352 16.9327 16.6522
150014...................................................... 21.2812 22.0143 21.5168 21.6212
150015...................................................... 22.0452 22.5409 21.9037 22.1546
150017...................................................... 18.8898 18.7664 19.5339 19.0694
150018...................................................... 19.5612 20.4947 21.0496 20.3869
150019...................................................... 15.2892 16.6327 17.8585 16.5672
150020...................................................... 14.4592 15.1120 16.6600 15.3745
150021...................................................... 19.0162 19.5096 21.5944 20.0447
150022...................................................... 17.9206 19.1555 17.9222 18.3309
150023...................................................... 18.6641 18.3598 19.3412 18.8110
150024...................................................... 17.8311 18.4140 19.2295 18.4561
150025...................................................... 18.1490 17.7007 20.2750 18.6347
150026...................................................... 20.5085 18.8417 22.4978 20.5355
[[Page 39978]]
150027...................................................... 16.4846 17.3284 18.0335 17.2600
150029...................................................... 21.7414 23.0546 23.2454 22.7440
150030...................................................... 17.3296 17.9992 19.2406 18.1943
150031...................................................... 18.0060 17.2429 18.3463 17.8675
150032...................................................... 20.6391 * * 20.6391
150033...................................................... 21.6854 21.8768 22.6741 22.0835
150034...................................................... 21.2868 22.1317 23.1533 22.1845
150035...................................................... 19.8177 20.4477 21.2374 20.5107
150036...................................................... 20.3848 20.8692 21.4567 20.9448
150037...................................................... 17.7868 21.7109 24.4611 21.1306
150038...................................................... 20.2503 21.2193 22.0572 21.2025
150039...................................................... 17.4919 18.4729 19.6215 18.5025
150042...................................................... 17.1241 18.1632 20.2221 18.3947
150043...................................................... 17.9834 19.0120 20.1741 18.9948
150044...................................................... 17.6432 18.4381 19.1309 18.4093
150045...................................................... 17.0395 16.8121 18.1670 17.3563
150046...................................................... 17.3210 17.6342 18.2543 17.7460
150047...................................................... 24.8819 19.7441 22.0145 22.1013
150048...................................................... 16.9573 19.3329 19.1648 18.5048
150049...................................................... 16.8529 17.0141 18.6451 17.4705
150050...................................................... 17.1442 16.8354 17.7354 17.2410
150051...................................................... 18.1990 19.0130 19.7257 18.9710
150052...................................................... 15.3618 15.8590 17.3750 16.2411
150053...................................................... 18.7463 19.1421 18.8632 18.9165
150054...................................................... 17.3296 17.3825 18.3916 17.7528
150056...................................................... 23.2991 22.4087 21.5774 22.2457
150057...................................................... 16.8630 16.5882 16.9736 16.8076
150058...................................................... 20.9537 20.8178 22.1409 21.3058
150059...................................................... 20.8004 21.2535 22.7360 21.5830
150060...................................................... 16.0098 17.0743 18.6159 17.2538
150061...................................................... 17.2141 17.3887 19.7968 18.0770
150062...................................................... 18.4110 20.5415 20.8274 20.0239
150063...................................................... 21.0899 22.0925 22.6525 21.9213
150064...................................................... 17.0309 18.1400 20.3865 18.5718
150065...................................................... 19.0051 19.8913 21.2153 20.0425
150066...................................................... 14.5977 15.3373 19.5313 16.4634
150067...................................................... 17.0829 18.2926 18.8862 18.0821
150069...................................................... 17.3918 21.5310 23.3969 20.9447
150070...................................................... 17.1992 17.9260 18.0827 17.7417
150071...................................................... 14.7306 13.4760 13.5111 13.9122
150072...................................................... 16.1091 16.2054 15.0765 15.7702
150073...................................................... 19.0292 22.2968 * 20.5664
150074...................................................... 18.8597 20.4175 20.2305 19.8210
150075...................................................... 14.9786 15.5603 16.7532 15.7414
150076...................................................... 22.3407 22.9382 22.6424 22.6387
150077...................................................... 17.5750 * * 17.5750
150078...................................................... 19.0096 19.2718 19.9668 19.4018
150079...................................................... 15.4545 17.2436 18.2051 16.9085
150082...................................................... 17.8796 17.5265 17.8381 17.7489
150084...................................................... 22.9159 23.2506 24.3107 23.4933
150086...................................................... 17.3442 18.9735 18.3838 18.2534
150088...................................................... 19.4475 18.9869 20.3366 19.5726
150089...................................................... 22.9458 23.8791 22.1725 22.9671
150090...................................................... 19.0595 20.7726 21.0945 20.2459
150091...................................................... 19.8912 20.4053 22.4640 20.9087
150092...................................................... 15.9174 16.7434 16.9179 16.5364
150094...................................................... 18.3410 16.5788 17.5244 17.5067
150095...................................................... 17.1187 17.1324 19.2749 17.7838
150096...................................................... 20.0281 23.2764 20.8204 21.3056
150097...................................................... 18.3103 19.3802 19.7751 19.1545
150098...................................................... 14.2953 15.0943 15.2829 14.8856
150099...................................................... 18.9718 22.4229 * 20.3545
150100...................................................... 17.4776 18.4148 19.8066 18.6620
[[Page 39979]]
150101...................................................... 17.5554 16.4604 20.6209 18.1130
150102...................................................... 11.5034 19.7426 23.7180 17.1422
150103...................................................... 17.3064 18.4781 18.7036 18.2137
150104...................................................... 17.2642 17.6981 20.0765 18.3399
150105...................................................... 19.1709 20.0431 22.4412 20.4692
150106...................................................... 18.9097 16.1510 16.8714 17.2294
150109...................................................... 18.2289 18.8077 19.9066 18.9623
150110...................................................... 18.5752 18.6627 21.9336 19.5289
150111...................................................... 16.1707 18.4556 19.2355 17.8619
150112...................................................... 19.8155 20.4109 20.5253 20.2569
150113...................................................... 19.1988 20.3780 19.6603 19.7455
150114...................................................... 16.9638 19.5183 17.9877 18.1743
150115...................................................... 17.0627 17.4315 18.4844 17.6591
150122...................................................... 19.3545 18.7139 17.7867 18.6097
150123...................................................... 15.1552 14.1105 14.0508 14.4522
150124...................................................... 15.0706 14.6245 15.9487 15.2180
150125...................................................... 20.3198 20.6735 21.3311 20.7806
150126...................................................... 20.2958 21.3697 20.6857 20.7640
150127...................................................... 22.8129 17.1994 17.0052 18.8048
150128...................................................... 19.9205 18.5100 19.5576 19.3346
150129...................................................... 23.4718 24.7711 28.6211 25.2796
150130...................................................... 16.4144 18.1971 18.4846 17.6635
150132...................................................... 19.4805 20.1684 20.9443 20.1836
150133...................................................... 16.4910 17.3966 18.4250 17.4061
150134...................................................... 17.0612 19.2526 19.3632 18.5912
150136...................................................... 19.2819 20.1245 21.8097 20.3987
150145...................................................... * 16.6851 * 16.6851
150146...................................................... * * 19.0204 19.0204
160001...................................................... 19.0279 18.6035 19.0085 18.8767
160002...................................................... 15.3724 15.9534 16.6003 15.9668
160003...................................................... 15.7747 16.0862 16.2208 16.0221
160005...................................................... 15.2320 17.6153 17.9405 16.9144
160007...................................................... 15.6638 13.2101 15.1738 14.6237
160008...................................................... 14.9698 15.9742 16.6193 15.8477
160009...................................................... 16.0919 16.8391 17.9886 16.9591
160012...................................................... 16.5409 16.4827 16.7112 16.5761
160013...................................................... 17.0602 18.3996 18.6304 18.0298
160014...................................................... 15.0861 15.9086 16.7146 15.8981
160016...................................................... 18.3710 19.6322 19.9747 19.3376
160018...................................................... 14.1634 14.5946 15.6141 14.7975
160020...................................................... 14.4135 15.4712 15.5384 15.1417
160021...................................................... 15.4860 16.5049 16.7617 16.2368
160023...................................................... 14.2015 15.0665 15.0099 14.7723
160024...................................................... 18.9548 19.7050 19.4764 19.3806
160026...................................................... 18.6624 18.8379 19.5260 19.0040
160027...................................................... 15.7403 16.3477 16.9417 16.3376
160028...................................................... 20.5416 19.9595 21.0000 20.4893
160029...................................................... 20.4003 20.4678 21.3457 20.7382
160030...................................................... 17.9860 19.9508 19.6182 19.1837
160031...................................................... 15.2831 15.2448 16.1267 15.5484
160032...................................................... 16.1820 17.3202 18.3168 17.2888
160033...................................................... 18.3736 18.8673 18.8859 18.7219
160034...................................................... 14.5053 15.0019 16.5957 15.3739
160035...................................................... 15.9199 15.2211 16.3991 15.8029
160036...................................................... 19.1984 17.8849 17.4558 18.1820
160037...................................................... 18.3968 19.0532 19.5045 18.9883
160039...................................................... 17.6272 17.4758 17.8647 17.6551
160040...................................................... 16.8295 18.1949 18.0667 17.6917
160041...................................................... 15.4700 16.7850 17.4435 16.5782
160043...................................................... 15.6261 15.6909 14.8564 15.3356
160044...................................................... 16.0385 16.7439 17.8323 16.9072
160045...................................................... 20.1154 20.1236 20.0611 20.1010
160046...................................................... 14.7672 14.5655 16.2737 15.1831
[[Page 39980]]
160047...................................................... 16.6926 18.3593 19.0787 18.0537
160048...................................................... 13.1417 14.6144 15.6856 14.5140
160049...................................................... 13.3614 14.5457 15.5673 14.5017
160050...................................................... 16.4161 17.4912 17.7878 17.2198
160051...................................................... 14.2660 14.6400 16.4261 15.1036
160052...................................................... 17.5509 18.0941 21.7647 19.2313
160054...................................................... 15.7093 16.1753 16.1981 16.0321
160055...................................................... 14.0647 14.7600 15.1674 14.6539
160056...................................................... 15.3758 16.1575 17.0172 16.1537
160057...................................................... 17.4101 18.1776 19.1378 18.2553
160058...................................................... 20.3402 21.1159 22.1061 21.1598
160060...................................................... 15.9527 16.0436 17.2825 16.3968
160061...................................................... 17.5707 17.3215 17.0938 17.3350
160062...................................................... 14.4433 17.8086 17.4388 16.4393
160063...................................................... 16.2960 16.8834 16.3583 16.5061
160064...................................................... 19.9135 20.5496 22.2131 20.9171
160065...................................................... 16.5087 16.9373 17.1043 16.8758
160066...................................................... 16.2651 17.1875 17.9971 17.1716
160067...................................................... 17.8551 17.8514 16.7833 17.4322
160068...................................................... 15.8526 17.9892 19.0572 17.5565
160069...................................................... 18.4857 19.7280 19.1640 19.1095
160070...................................................... 15.6647 16.7017 18.4588 16.9299
160072...................................................... 14.1920 14.9536 14.4141 14.5422
160073...................................................... 15.0526 11.8261 11.4997 12.6736
160074...................................................... 16.4772 19.5092 17.9513 18.0038
160075...................................................... 17.8870 19.4948 18.4613 18.6342
160076...................................................... 17.3086 17.9381 17.8824 17.7060
160077...................................................... 11.4028 12.8826 13.6658 12.6451
160079...................................................... 17.7050 17.6187 18.6333 17.9899
160080...................................................... 17.8143 18.6687 19.4925 18.6704
160081...................................................... 16.5150 17.0052 17.4466 17.0164
160082...................................................... 18.7630 19.6499 19.5322 19.3143
160083...................................................... 18.4078 20.6189 19.7542 19.5937
160085...................................................... 18.5510 18.0063 21.2557 19.2281
160086...................................................... 16.4558 17.3271 17.5308 17.0998
160088...................................................... 17.5331 20.2331 22.3655 19.9346
160089...................................................... 16.7419 16.9538 17.3449 17.0079
160090...................................................... 16.6002 17.1090 17.9614 17.2461
160091...................................................... 12.1893 12.8516 14.2573 13.0755
160092...................................................... 15.7979 15.5011 17.0633 16.0971
160093...................................................... 15.9525 17.7457 18.5675 17.5141
160094...................................................... 16.5609 18.7653 17.6094 17.6731
160095...................................................... 14.2649 15.1895 15.2722 14.9322
160097...................................................... 15.2079 15.9263 16.6790 15.9380
160098...................................................... 15.5385 16.3135 16.8670 16.2509
160099...................................................... 13.7864 13.9053 15.0880 14.2533
160101...................................................... 17.8654 18.3705 18.9788 18.3824
160102...................................................... 18.3631 18.8765 20.1161 19.0875
160103...................................................... 17.1519 17.0973 18.2741 17.4869
160104...................................................... 19.7387 18.8301 17.4829 18.7797
160106...................................................... 16.6624 16.9639 17.3474 16.9910
160107...................................................... 16.5622 18.0634 18.0097 17.5762
160108...................................................... 15.4183 16.0529 16.7779 16.0861
160109...................................................... 16.4885 16.5593 17.9873 16.9740
160110...................................................... 18.8056 19.1420 20.6215 19.5351
160111...................................................... 13.1689 14.1644 14.9965 14.0808
160112...................................................... 16.2829 16.8332 17.2450 16.7911
160113...................................................... 14.5838 14.7097 15.4834 14.9308
160114...................................................... 15.5812 16.1423 16.5006 16.0651
160115...................................................... 15.7566 15.8995 16.5654 16.0764
160116...................................................... 16.6927 16.9534 16.6993 16.7818
160117...................................................... 17.2914 17.9410 18.7615 17.9848
160118...................................................... 15.8351 17.2523 19.4472 17.5046
[[Page 39981]]
160120...................................................... 12.5642 10.5992 15.6789 12.4454
160122...................................................... 18.5214 18.9252 18.1469 18.5357
160124...................................................... 17.1642 18.0908 19.1600 18.1198
160126...................................................... 17.7397 17.8142 19.4903 18.3068
160129...................................................... 15.8914 16.7131 17.2112 16.5953
160130...................................................... 15.4477 16.0528 15.6666 15.7242
160131...................................................... 14.6874 15.4898 16.0424 15.4292
160134...................................................... 13.3246 13.4743 15.3012 14.0359
160135...................................................... 16.3294 18.2682 18.7711 17.7744
160138...................................................... 15.7076 16.8699 17.1491 16.5906
160140...................................................... 18.7962 18.4007 18.5630 18.5823
160142...................................................... 16.1372 16.2875 18.1467 16.8318
160143...................................................... 15.9240 16.6154 17.4497 16.6799
160145...................................................... 15.1745 13.9152 16.9092 15.2763
160146...................................................... 16.3532 16.6024 17.7010 16.8728
160147...................................................... 18.3917 17.4880 19.4041 18.3938
160151...................................................... 15.7384 16.8257 17.2177 16.5833
160152...................................................... 15.2179 15.6170 15.9500 15.5914
160153...................................................... 19.6927 20.2316 21.2085 20.3741
170001...................................................... 17.4383 17.9304 17.9218 17.7616
170004...................................................... 13.0635 15.0636 16.1442 14.7434
170006...................................................... 19.3075 17.2192 17.5982 17.9438
170008...................................................... 13.9009 14.9124 16.8412 15.1327
170009...................................................... 19.5867 20.7795 23.1349 21.2143
170010...................................................... 17.8995 18.7384 19.4584 18.6890
170012...................................................... 16.7886 17.8719 18.4432 17.7137
170013...................................................... 17.8949 18.6454 19.4667 18.6963
170014...................................................... 17.3379 17.9349 18.4931 17.9333
170015...................................................... 15.8887 16.5750 17.1302 16.5216
170016...................................................... 19.6393 19.2130 20.0675 19.6307
170017...................................................... 17.8690 17.7958 19.5994 18.4143
170018...................................................... 14.2759 15.2984 15.3237 14.9817
170019...................................................... 16.6611 15.2094 16.9362 16.2597
170020...................................................... 16.1460 17.3400 18.1325 17.2351
170022...................................................... 17.9383 18.5309 19.1888 18.5543
170023...................................................... 19.3585 19.1351 19.2441 19.2444
170024...................................................... 13.0566 13.6803 14.3604 13.6835
170025...................................................... 16.3716 17.8667 18.7182 17.6087
170026...................................................... 13.3122 15.0470 14.8974 14.3412
170027...................................................... 16.3859 17.3604 17.8690 17.2095
170030...................................................... 15.2397 14.6530 15.9282 15.2488
170031...................................................... 13.4670 13.9601 14.2151 13.8715
170032...................................................... 14.4835 15.6093 16.3449 15.4817
170033...................................................... 16.0529 16.4059 19.1952 17.1087
170034...................................................... 14.6349 15.8202 16.9586 15.7633
170035...................................................... 15.6240 18.5885 17.0945 17.0832
170036...................................................... 14.1732 * * 14.1732
170038...................................................... 14.2092 14.7776 13.8582 14.2922
170039...................................................... 14.2952 15.8635 17.0774 15.7642
170040...................................................... 20.1419 21.6440 21.0617 20.9374
170041...................................................... 11.4691 11.7566 12.4488 11.8690
170044...................................................... 14.7801 15.3011 17.3254 15.8168
170045...................................................... 12.1066 14.0875 25.8331 16.7874
170049...................................................... 18.5821 19.9415 20.7921 19.8083
170051...................................................... 14.1572 15.0889 16.4851 15.2703
170052...................................................... 14.6176 15.0108 15.2283 14.9500
170053...................................................... 9.0407 16.5102 14.6133 11.9759
170054...................................................... 12.7655 14.4353 14.6354 13.9214
170055...................................................... 14.9875 16.9800 18.2607 16.7698
170056...................................................... 14.8656 17.0442 18.3550 16.8283
170057...................................................... 15.0892 13.0007 * 13.9776
170058...................................................... 18.3389 18.6983 19.5415 18.8159
170060...................................................... 17.2271 17.3482 18.9853 17.7512
[[Page 39982]]
170061...................................................... 14.1380 15.6527 15.0258 14.9459
170063...................................................... 11.3284 12.8082 14.1185 12.6216
170064...................................................... 12.4183 * * 12.4183
170066...................................................... 14.4790 15.5322 16.2891 15.4168
170067...................................................... 12.7846 14.7492 14.9921 14.1535
170068...................................................... 15.8175 15.1790 17.0022 15.9795
170070...................................................... 12.8158 14.2445 14.0627 13.7083
170072...................................................... 13.3379 12.6329 12.7709 12.9159
170073...................................................... 16.4690 17.5368 17.7056 17.2186
170074...................................................... 14.4009 17.5537 17.3699 16.4326
170075...................................................... 11.2598 12.4212 13.6816 12.5950
170076...................................................... 13.5820 14.5866 14.6109 14.2394
170077...................................................... 12.7244 13.5235 13.9104 13.3651
170079...................................................... 14.2859 13.5261 11.5902 13.1470
170080...................................................... 12.2012 12.6014 14.8293 13.1562
170081...................................................... 12.5122 13.8077 14.6823 13.7421
170082...................................................... 12.3902 12.8563 13.7462 12.9854
170084...................................................... 12.1611 12.5410 13.0519 12.5742
170085...................................................... 14.5069 15.4518 17.5422 15.9150
170086...................................................... 19.8496 20.4068 19.7182 19.9991
170088...................................................... 11.7505 13.4542 13.4860 12.9031
170089...................................................... 18.0823 18.8136 15.4860 17.4574
170090...................................................... 11.2747 11.9147 10.9444 11.3947
170092...................................................... 12.8507 * * 12.8507
170093...................................................... 12.7780 13.5490 14.0276 13.4193
170094...................................................... 17.7091 20.1985 21.2035 19.6936
170095...................................................... 15.7469 15.5463 15.3532 15.5482
170097...................................................... 15.8504 16.4608 17.7540 16.7203
170098...................................................... 14.1026 15.5259 16.6210 15.4425
170099...................................................... 13.5509 13.6033 14.3370 13.8072
170100...................................................... 14.4700 * * 14.4700
170101...................................................... 12.8847 14.5629 18.0143 14.7718
170102...................................................... 13.2434 13.6321 14.2447 13.7065
170103...................................................... 16.6578 17.2844 17.9530 17.2887
170104...................................................... 19.7645 20.6182 21.0049 20.4661
170105...................................................... 15.9290 16.5408 16.7403 16.4083
170106...................................................... 14.6773 18.5479 17.7467 16.9030
170109...................................................... 16.9421 17.2629 16.9782 17.0622
170110...................................................... 15.5549 16.9823 18.5731 17.1658
170112...................................................... 13.3908 14.3855 15.4049 14.4270
170113...................................................... 13.3935 13.9038 14.6486 13.9920
170114...................................................... 14.5116 14.4545 16.2645 15.0138
170115...................................................... 12.6815 12.6997 12.9216 12.7709
170116...................................................... 15.7566 16.8714 18.1830 16.9494
170117...................................................... 15.2818 15.7875 16.8237 15.8968
170119...................................................... 13.9673 15.1990 15.2708 14.7822
170120...................................................... 16.2122 17.6748 17.4917 17.1241
170122...................................................... 20.1266 20.0615 21.1769 20.4366
170123...................................................... 21.4168 23.1697 23.6534 22.7009
170124...................................................... 10.2089 11.1249 15.0596 11.8247
170126...................................................... 12.1268 12.8096 13.5736 12.8129
170128...................................................... 14.9919 14.8891 14.1676 14.6301
170131...................................................... 13.0978 10.1000 * 11.3849
170133...................................................... 17.1103 18.0243 18.8119 17.9917
170134...................................................... 14.2252 14.1085 14.6799 14.3402
170137...................................................... 17.4151 17.8290 19.3118 18.1884
170139...................................................... 13.3896 14.1967 14.3001 13.9545
170142...................................................... 17.3234 * 17.7134 17.5177
170143...................................................... 15.8802 15.6509 16.0415 15.8575
170144...................................................... 16.0860 19.0929 20.4392 18.4073
170145...................................................... 16.7499 17.1837 19.0142 17.6442
170146...................................................... 19.9725 20.9075 21.7919 20.9132
170147...................................................... 16.2829 22.3017 17.6717 18.6905
[[Page 39983]]
170148...................................................... 17.2497 16.9183 19.1942 17.6867
170150...................................................... 15.4283 15.5651 15.9072 15.6422
170151...................................................... 13.3674 13.8934 14.3668 13.8637
170152...................................................... 13.6846 14.9139 15.6423 14.7323
170160...................................................... 13.3087 13.7108 14.4732 13.8369
170164...................................................... 15.5597 16.6542 17.4072 16.5279
170166...................................................... 17.5681 27.5567 12.7507 18.3396
170171...................................................... 13.8059 12.5200 13.1792 13.1761
170175...................................................... 17.8802 19.0232 20.1907 18.9985
170176...................................................... 20.3194 21.3400 23.5043 21.7098
170180...................................................... * 16.6921 8.6352 11.8552
170182...................................................... 14.1971 22.2164 21.3454 19.8791
170183...................................................... 19.0919 20.3505 19.5182 19.7036
170184...................................................... 27.0152 * * 27.0152
180001...................................................... 19.5188 17.9906 20.4885 19.3882
180002...................................................... 18.1348 17.9669 17.5798 17.8819
180004...................................................... 15.9921 17.2581 17.7149 16.9654
180005...................................................... 20.6280 21.1390 22.4634 21.3796
180006...................................................... 11.2254 11.4398 10.3400 11.0123
180007...................................................... 17.1997 17.6776 17.9491 17.6005
180009...................................................... 20.8103 21.4730 21.0608 21.1163
180010...................................................... 17.5452 19.1100 19.6311 18.7406
180011...................................................... 16.9311 17.1050 19.0526 17.8588
180012...................................................... 18.7350 18.7223 19.0646 18.8428
180013...................................................... 17.4487 18.2354 19.7418 18.5305
180014...................................................... 20.8033 21.4856 21.3361 21.1759
180016...................................................... 18.8422 19.8892 21.1458 20.0187
180017...................................................... 15.1699 15.4140 15.6583 15.4240
180018...................................................... 18.9020 17.1692 15.4892 17.0584
180019...................................................... 16.7648 17.3970 17.8285 17.3565
180020...................................................... 17.7782 17.7288 18.0111 17.8397
180021...................................................... 15.1627 15.4580 17.0618 15.8957
180023...................................................... 15.2219 15.8803 17.4717 16.1885
180024...................................................... 15.3299 16.1731 16.5040 15.9951
180025...................................................... 17.1688 14.1841 15.4180 15.4826
180026...................................................... 14.1571 14.6804 15.0118 14.6082
180027...................................................... 14.8869 16.4116 17.5286 16.2087
180028...................................................... 19.3519 19.5276 15.7005 18.0068
180029...................................................... 18.0191 17.7729 17.7248 17.8352
180030...................................................... 17.0234 17.3430 17.9543 17.4342
180031...................................................... 13.7862 13.9844 13.1848 13.6178
180032...................................................... 16.0941 16.8318 17.2784 16.7976
180033...................................................... 13.7667 17.7344 15.4131 15.5472
180034...................................................... 17.3158 15.3369 16.3991 16.3000
180035...................................................... 19.4485 20.1305 21.3666 20.2870
180036...................................................... 19.1922 19.8398 20.1860 19.7448
180037...................................................... 18.8053 19.9737 21.2184 19.9797
180038...................................................... 17.1643 17.7626 18.5923 17.8512
180040...................................................... 19.4450 19.5337 21.2229 20.0583
180041...................................................... 15.1703 15.0785 16.3699 15.5655
180042...................................................... 16.2924 16.7691 17.1519 16.7450
180043...................................................... 16.6077 16.8027 14.6526 15.9643
180044...................................................... 17.8196 18.5571 19.4984 18.6534
180045...................................................... 17.7272 17.7130 20.8455 18.9499
180046...................................................... 17.9096 19.2523 21.2080 19.4569
180047...................................................... 15.0354 16.2304 18.6938 16.6027
180048...................................................... 19.5681 18.3442 17.7816 18.5208
180049...................................................... 16.0799 16.4319 16.5459 16.3594
180050...................................................... 18.4753 17.8540 17.1493 17.7884
180051...................................................... 15.6796 16.3960 17.5441 16.5170
180053...................................................... 14.6299 15.9284 15.8994 15.5002
180054...................................................... 16.3875 19.4858 20.0946 18.5771
180055...................................................... 14.6446 15.2663 15.8422 15.2446
[[Page 39984]]
180056...................................................... 16.6240 17.0056 17.5881 17.0744
180058...................................................... 14.3562 15.9685 14.5355 14.9226
180059...................................................... 14.2605 13.3955 14.7032 14.1102
180060...................................................... 7.2139 * * 7.2139
180063...................................................... 11.9120 13.1036 12.4448 12.4785
180064...................................................... 14.4872 15.2424 15.5066 15.0871
180065...................................................... 20.0286 12.0629 11.1934 13.8815
180066...................................................... 18.5635 19.2981 19.8956 19.2578
180067...................................................... 18.5288 20.6322 20.1712 19.7577
180069...................................................... 17.2956 17.7911 16.2916 17.1149
180070...................................................... 13.8370 13.1923 15.9362 14.2840
180072...................................................... 17.8554 16.9021 17.2347 17.3229
180075...................................................... 15.0701 * * 15.0701
180078...................................................... 19.1615 21.1170 21.7116 20.6787
180079...................................................... 13.4072 15.1636 15.9048 14.8197
180080...................................................... 15.8327 16.4989 16.6428 16.3363
180087...................................................... 14.9660 14.9167 15.6089 15.1555
180088...................................................... 22.5349 22.0374 22.1774 22.2484
180092...................................................... 16.3099 18.2405 18.3597 17.6633
180093...................................................... 16.8286 17.0132 17.8492 17.2232
180094...................................................... 12.5074 13.5490 13.6233 13.2263
180095...................................................... 13.3991 13.8021 13.9050 13.6989
180099...................................................... 13.6988 13.3631 13.2991 13.4593
180101...................................................... 19.5644 18.4883 * 18.9778
180102...................................................... 17.8751 17.9618 18.5240 18.1008
180103...................................................... 19.2182 19.8965 20.3490 19.8359
180104...................................................... 18.8730 18.9281 19.3922 19.0643
180105...................................................... 14.0811 15.2394 16.6997 15.2994
180106...................................................... 13.6062 14.3505 15.2895 14.3903
180108...................................................... 14.6222 14.8187 14.4740 14.6381
180115...................................................... 17.1079 16.7003 16.9096 16.9026
180116...................................................... 16.9389 18.0392 18.6077 17.8709
180117...................................................... 18.3821 17.7857 23.0192 19.6584
180118...................................................... 12.1533 15.8597 16.9250 14.8270
180120...................................................... 17.8145 16.1591 15.3115 16.3371
180121...................................................... 14.5134 15.0983 20.0494 16.3330
180122...................................................... 16.9678 18.5094 18.1930 17.8754
180123...................................................... 18.9995 21.0613 21.1067 20.4023
180124...................................................... 18.4064 17.4994 18.8487 18.2269
180125...................................................... 19.7341 19.6416 14.9314 17.5744
180126...................................................... 12.3959 12.9228 14.3551 13.2733
180127...................................................... 17.3452 19.2581 17.6365 18.0663
180128...................................................... 17.0508 17.6385 18.2817 17.6802
180129...................................................... 17.8600 16.8378 22.3536 18.8696
180130...................................................... 19.0110 19.8192 20.6450 19.8370
180132...................................................... 17.2657 17.7744 19.5884 18.2006
180133...................................................... 22.2325 21.6794 21.7800 21.8995
180134...................................................... 13.6287 13.1935 14.5387 13.7967
180136...................................................... 17.7146 17.3542 * 17.5359
180138...................................................... 18.6149 19.3692 20.2102 19.4170
180139...................................................... 18.7679 18.7198 20.5350 19.3756
180140...................................................... 20.3953 16.8152 15.2719 17.3915
180141...................................................... 20.0075 20.9820 23.8930 21.4590
180142...................................................... * * 20.7510 20.7510
190001...................................................... 17.0159 17.6832 18.1514 17.6263
190002...................................................... 18.8381 19.1924 19.8834 19.2931
190003...................................................... 22.1543 19.7749 19.9121 20.4811
190004...................................................... 17.5385 17.7710 18.3620 17.8959
190005...................................................... 16.7149 17.2422 17.5161 17.1568
190006...................................................... 17.7335 17.8036 17.5911 17.7112
190007...................................................... 13.6014 13.8189 14.4720 13.9833
190008...................................................... 16.8916 18.6664 19.2456 18.2327
190009...................................................... 14.2085 15.3555 15.9731 15.1819
[[Page 39985]]
190010...................................................... 17.0192 16.2805 16.5020 16.6088
190011...................................................... 15.1715 15.9534 15.6351 15.5881
190013...................................................... 16.5706 16.8181 15.5019 16.2739
190014...................................................... 17.0170 17.0959 17.8015 17.3107
190015...................................................... 18.1943 18.6266 18.9896 18.6153
190017...................................................... 15.7894 16.2393 17.5381 16.5250
190018...................................................... 16.9761 15.0668 11.1898 14.5841
190019...................................................... 17.4006 18.5257 18.3788 18.1281
190020...................................................... 17.3084 17.5256 17.6840 17.5059
190025...................................................... 16.0738 18.6369 16.8686 17.2271
190026...................................................... 17.2166 18.1622 18.5015 17.9532
190027...................................................... 16.1856 17.0827 17.4761 16.9034
190029...................................................... 17.1103 16.5239 19.1967 17.5497
190033...................................................... 10.7448 * * 10.7448
190034...................................................... 16.5066 16.8503 18.0754 17.1513
190036...................................................... 19.9456 20.1780 20.0300 20.0491
190037...................................................... 12.0237 17.6945 19.9878 16.0686
190039...................................................... 17.1687 19.4713 19.0376 18.5119
190040...................................................... 20.3180 21.4634 21.7376 21.1907
190041...................................................... 17.8975 17.6646 17.9535 17.8382
190043...................................................... 12.5660 15.5580 15.5618 14.5094
190044...................................................... 17.1984 17.2892 17.4471 17.3108
190045...................................................... 21.6948 21.6107 21.2853 21.5139
190046...................................................... 19.3538 19.7964 20.4458 19.8736
190048...................................................... 16.3404 16.6683 16.8136 16.6153
190049...................................................... 16.4250 17.2280 17.7417 17.1570
190050...................................................... 15.3771 16.1980 16.2854 15.9545
190053...................................................... 12.4980 13.2159 13.0080 12.9160
190054...................................................... 16.4683 19.1738 18.9059 18.1924
190059...................................................... 15.8443 15.6942 15.8373 15.7915
190060...................................................... 18.3689 14.7186 17.8443 16.7639
190064...................................................... 19.9047 20.4482 18.2466 19.4909
190065...................................................... 19.3856 20.9927 18.3091 19.5174
190071...................................................... 13.5908 14.4827 16.4138 14.8320
190077...................................................... 12.8290 15.7805 16.5536 15.0793
190078...................................................... 13.4990 14.8826 16.9383 14.8793
190079...................................................... 17.2909 17.7120 17.9403 17.6368
190081...................................................... 12.0190 15.3198 14.9707 14.2301
190083...................................................... 16.1374 18.8895 18.4951 17.8399
190086...................................................... 14.9295 15.8694 16.5074 15.7738
190088...................................................... 19.6328 20.5531 19.9362 20.0391
190089...................................................... 12.7879 13.0503 15.0395 13.5823
190090...................................................... 16.5580 16.6664 16.2351 16.4928
190092...................................................... 18.0655 * * 18.0655
190095...................................................... 15.7316 16.2287 17.3258 16.3915
190098...................................................... 19.2175 20.4897 21.0847 20.2301
190099...................................................... 18.9255 19.9018 19.0635 19.3257
190102...................................................... 19.0477 20.0300 20.7870 19.9631
190103...................................................... 15.5698 12.1389 14.4158 13.8580
190106...................................................... 17.7468 18.5813 18.5908 18.3281
190109...................................................... 14.5288 15.5767 15.8187 15.3068
190110...................................................... 12.9925 15.8052 15.7313 14.8387
190111...................................................... 20.0376 19.7514 20.6508 20.1574
190112...................................................... 19.2067 21.0232 22.0741 20.6951
190113...................................................... 18.9922 12.5777 * 15.7380
190114...................................................... 12.9083 12.6366 13.9209 13.1568
190115...................................................... 20.4914 20.2473 22.7583 21.1252
190116...................................................... 12.5881 15.5481 17.3757 15.1678
190118...................................................... 12.9537 14.7876 16.3776 14.7222
190120...................................................... 13.6938 13.9591 17.2309 14.9846
190122...................................................... 14.8255 15.4793 15.3742 15.2287
190124...................................................... 22.3825 20.6222 20.1206 20.9375
190125...................................................... 18.6287 20.4517 19.8298 19.6458
[[Page 39986]]
190128...................................................... 19.7127 20.4688 20.8770 20.3583
190130...................................................... 12.4307 15.1467 14.0379 13.8956
190131...................................................... 19.5984 20.7565 18.8958 19.7536
190133...................................................... 13.4750 13.5383 15.1393 13.9917
190134...................................................... 12.6774 12.1749 12.4507 12.4351
190135...................................................... 21.3511 21.6875 21.3454 21.4650
190136...................................................... 11.3250 12.4091 15.1662 13.0730
190138...................................................... 22.7088 * * 22.7088
190140...................................................... 12.0285 14.2256 14.6829 13.6611
190142...................................................... 14.9820 15.4861 16.2280 15.5517
190144...................................................... 16.8360 16.2068 18.4405 17.1561
190145...................................................... 13.9893 15.2345 16.2505 15.1638
190146...................................................... 20.0941 21.2825 21.9607 21.1552
190147...................................................... 14.3219 14.4345 14.7202 14.4910
190148...................................................... 14.0180 16.6337 15.5338 15.4604
190149...................................................... 15.1862 17.5997 16.4722 16.4169
190151...................................................... 11.9190 14.7333 15.5210 14.0028
190152...................................................... 20.3951 22.2070 22.0319 21.4716
190155...................................................... 11.0800 * * 11.0800
190156...................................................... 12.4786 15.7478 16.0442 14.6766
190158...................................................... 19.6164 20.4637 20.4078 20.1474
190160...................................................... 18.4746 17.1003 18.4662 18.0078
190161...................................................... 14.6295 15.5737 15.9280 15.3544
190162...................................................... 19.5027 20.6143 20.1962 20.0440
190164...................................................... 16.3328 15.1783 18.2379 16.4778
190167...................................................... 16.2880 16.6681 17.7611 16.9143
190170...................................................... 13.5772 14.1750 14.5222 14.0895
190173...................................................... 19.6362 23.6398 23.0934 22.0602
190175...................................................... 20.6908 19.3625 20.4580 20.1298
190176...................................................... 18.8205 24.0574 22.2316 21.4596
190177...................................................... 20.3177 18.6715 19.7794 19.5846
190178...................................................... 10.4941 11.0657 12.0372 11.1714
190182...................................................... 20.0267 20.2855 20.7102 20.3281
190183...................................................... 16.1064 16.7671 16.0752 16.3134
190184...................................................... 14.8645 17.2044 19.8436 17.2547
190185...................................................... 19.3707 20.1444 20.5852 20.0405
190186...................................................... 16.3586 18.7568 17.4078 17.5306
190189...................................................... 26.5419 * * 26.5419
190190...................................................... 18.6656 17.4642 15.8985 17.1134
190191...................................................... 18.1353 20.4975 19.6911 19.4475
190196...................................................... 14.8699 17.9225 18.6138 17.2784
190197...................................................... 17.9166 19.5569 20.2082 19.2721
190199...................................................... 13.4222 16.0637 15.3522 14.6078
190200...................................................... 19.4148 22.0391 21.6852 21.0397
190201...................................................... 19.1432 18.7079 19.7421 19.2055
190202...................................................... 17.8959 * * 17.8959
190203...................................................... 21.3096 21.7350 21.7931 21.5975
190204...................................................... 21.2119 21.4624 20.5784 21.0754
190205...................................................... 18.1007 19.6587 19.3737 19.0483
190206...................................................... 20.0648 21.7012 21.3307 21.0222
190207...................................................... 17.6712 20.5082 19.0216 19.1034
190208...................................................... 14.6096 20.0065 16.9641 17.1855
190218...................................................... 18.1627 19.7518 19.2992 19.0335
190223...................................................... 19.2550 * * 19.2550
190227...................................................... 12.1086 * * 12.1086
190231...................................................... 16.8850 15.8287 17.7247 16.7665
190235...................................................... 18.2702 * * 18.2702
190236...................................................... 22.1837 19.3395 21.1982 20.9440
190238...................................................... * * 20.6799 20.6799
190239...................................................... * * 19.7601 19.7601
190240...................................................... * * 14.3579 14.3579
200001...................................................... 17.4890 18.0527 18.2513 17.9448
200002...................................................... 18.7745 19.3629 22.3035 20.2028
[[Page 39987]]
200003...................................................... 16.7389 16.9566 18.4141 17.3782
200006...................................................... 19.7984 17.6586 21.0922 19.4856
200007...................................................... 17.8859 18.7992 18.1681 18.2871
200008...................................................... 20.5020 21.7489 21.5556 21.2780
200009...................................................... 20.6433 22.2280 21.4763 21.4574
200012...................................................... 17.0130 18.3484 19.1047 18.1711
200013...................................................... 16.4933 18.0566 17.9378 17.5422
200015...................................................... 20.1117 * * 20.1117
200016...................................................... 17.6623 18.0866 17.1187 17.6192
200017...................................................... 19.6462 17.2930 * 18.7598
200018...................................................... 17.2422 18.5397 17.8675 17.8479
200019...................................................... 18.6399 19.2348 19.9245 19.2946
200020...................................................... 20.5967 22.4526 22.3355 21.8088
200021...................................................... 19.4052 19.9133 20.7361 19.9988
200023...................................................... 14.9164 16.1707 20.2063 16.7560
200024...................................................... 18.6518 19.4329 20.8336 19.6454
200025...................................................... 19.0659 20.2259 20.4165 19.9282
200026...................................................... 17.2842 18.1194 17.9021 17.7766
200027...................................................... 18.2775 18.5659 19.4220 18.7949
200028...................................................... 16.9306 19.5708 18.8763 18.4290
200031...................................................... 15.9043 16.2217 16.1641 16.1005
200032...................................................... 17.9160 18.9315 19.4613 18.7411
200033...................................................... 21.4031 21.8634 22.4685 21.9155
200034...................................................... 19.2407 20.1519 20.4941 19.9680
200037...................................................... 18.2419 18.6713 20.3015 19.1236
200038...................................................... 19.2147 23.3851 21.2632 21.2824
200039...................................................... 20.2901 19.8589 20.1508 20.0694
200040...................................................... 19.2970 19.5503 18.9580 19.2627
200041...................................................... 17.6559 19.3563 18.8131 18.6006
200043...................................................... 16.5368 16.7224 19.4295 17.5199
200050...................................................... 18.0805 20.1214 20.2014 19.5017
200051...................................................... 19.5925 22.1525 22.0712 21.5149
200052...................................................... 15.1216 17.2099 17.6271 16.6895
200055...................................................... 17.1729 18.8422 18.5983 18.1835
200062...................................................... 16.5139 17.2273 18.4279 17.3769
200063...................................................... 19.6658 19.9331 21.2121 20.2562
200066...................................................... 16.3431 17.0289 17.0570 16.8076
210001...................................................... 18.7266 20.4841 18.6617 19.2372
210002...................................................... 22.8448 19.9219 23.5132 22.2827
210003...................................................... 25.3730 20.3446 26.0447 23.6583
210004...................................................... 23.5884 24.2909 24.9760 24.2880
210005...................................................... 19.6162 21.4929 21.3829 20.7876
210006...................................................... 17.7721 18.9436 19.3682 18.7016
210007...................................................... 21.5415 23.1007 23.8840 22.8043
210008...................................................... 19.5006 21.1768 21.2895 20.6531
210009...................................................... 21.8111 20.5447 20.7479 21.0282
210010...................................................... 14.3783 18.7197 19.5908 17.3758
210011...................................................... 21.2422 21.4862 21.4043 21.3727
210012...................................................... 23.4317 20.7203 21.3977 21.7764
210013...................................................... 18.8455 19.7288 19.4505 19.3405
210015...................................................... 16.6898 16.1912 18.7448 17.2340
210016...................................................... 22.1469 23.8739 26.5193 24.0991
210017...................................................... 17.1747 18.8928 18.5079 18.1448
210018...................................................... 21.4055 22.2135 22.8553 22.1574
210019...................................................... 19.0899 19.3046 20.6025 19.6453
210022...................................................... 21.8160 22.6389 24.5744 23.0098
210023...................................................... 21.7988 23.1950 22.9989 22.6719
210024...................................................... 19.5645 20.6011 24.4280 21.4080
210025...................................................... 19.5704 19.5876 21.2769 20.0208
210026...................................................... 11.6440 12.1348 13.8668 12.6171
210027...................................................... 18.4862 17.6855 17.1060 17.7943
210028...................................................... 18.8623 19.6408 19.4157 19.3091
210029...................................................... 22.3876 21.2167 25.4939 23.0892
[[Page 39988]]
210030...................................................... 21.0169 21.7403 20.9574 21.2261
210031...................................................... 15.5873 16.2299 * 15.9014
210032...................................................... 18.4983 17.7228 20.1955 18.7972
210033...................................................... 19.9144 20.8053 23.7588 21.3886
210034...................................................... 16.1216 15.7322 19.4144 17.1228
210035...................................................... 20.6092 20.2731 20.8317 20.5720
210037...................................................... 18.7361 18.3072 20.5528 19.2053
210038...................................................... 23.2616 23.4971 24.9762 23.8679
210039...................................................... 20.7291 19.9901 21.3559 20.7067
210040...................................................... 25.0770 21.5014 23.4252 23.3184
210043...................................................... 18.5891 19.6474 22.4000 20.0973
210044...................................................... 22.2438 22.5781 23.0917 22.6329
210045...................................................... 9.6862 11.6086 12.1467 11.1781
210048...................................................... 22.3923 23.0537 24.6921 23.3434
210049...................................................... 17.6697 19.0821 19.3022 18.6991
210051...................................................... 20.7633 22.4335 23.6476 22.3235
210054...................................................... 23.5122 22.3559 23.2730 23.0396
210055...................................................... 20.1012 29.2539 26.5272 25.0062
210056...................................................... 20.9445 19.2662 22.9593 21.0605
210057...................................................... 22.5717 23.8289 26.0076 24.0668
210058...................................................... 21.4976 22.0753 16.3191 20.0884
210059...................................................... 23.1274 22.6766 25.6052 23.5899
210060...................................................... * * 26.5846 26.5846
210061...................................................... 20.0203 17.2240 16.1931 17.8181
220001...................................................... 26.3207 21.9369 22.9064 22.9526
220002...................................................... 22.5808 24.1285 16.3789 20.4063
220003...................................................... 19.1383 16.9246 17.9319 17.9948
220004...................................................... 20.0058 * * 20.0058
220006...................................................... 22.1228 22.3085 22.6337 22.3566
220008...................................................... 21.8873 24.4691 22.0796 22.7689
220010...................................................... 21.9226 21.8582 22.0067 21.9297
220011...................................................... 28.5673 26.1827 29.5290 28.2047
220012...................................................... 29.5051 32.0829 31.2303 30.9286
220015...................................................... 21.7813 22.5773 23.1893 22.4843
220016...................................................... 23.1440 23.3750 23.0951 23.2050
220017...................................................... 25.2630 22.4605 25.1568 24.2781
220019...................................................... 19.1264 19.5613 19.8551 19.5190
220020...................................................... 19.9925 21.4152 22.4295 21.2738
220021...................................................... 23.6313 * * 23.6313
220023...................................................... 18.7625 16.1885 * 18.0910
220024...................................................... 21.5871 21.5363 21.9316 21.6947
220025...................................................... 19.9398 20.7882 22.8593 21.1235
220028...................................................... 22.0721 22.8036 21.0630 21.9530
220029...................................................... 21.8711 23.1509 25.6560 23.4858
220030...................................................... 14.5383 18.5441 18.7429 17.2580
220031...................................................... 28.1584 30.2430 29.3091 29.1415
220033...................................................... 20.4120 20.0695 20.3609 20.2712
220035...................................................... 21.9974 21.6396 23.1892 22.2365
220036...................................................... 24.1570 24.6470 24.4091 24.3977
220038...................................................... 22.3494 22.6518 22.3162 22.4382
220041...................................................... 23.1483 23.4720 27.5034 24.5999
220042...................................................... 25.2852 25.0779 26.0473 25.4181
220046...................................................... 22.4677 22.7068 23.3149 22.8459
220049...................................................... 23.0283 26.0025 27.2689 25.4891
220050...................................................... 20.8345 22.0144 22.5265 21.7871
220051...................................................... 20.4765 21.1033 21.7357 21.0973
220052...................................................... 23.1376 23.7650 23.5225 23.4708
220053...................................................... 21.2679 19.1280 * 20.2813
220055...................................................... 21.5706 21.3743 * 21.4727
220057...................................................... 23.0010 25.3902 25.8064 24.6606
220058...................................................... 20.1888 19.9369 26.8345 22.1915
220060...................................................... 26.1753 28.0843 28.0794 27.4392
220062...................................................... 20.0560 20.4685 20.2254 20.2505
[[Page 39989]]
220063...................................................... 20.9547 20.3951 20.8079 20.7132
220064...................................................... 22.1785 22.3260 22.7497 22.4060
220065...................................................... 20.1974 20.1364 20.1424 20.1584
220066...................................................... 20.4586 20.7826 23.4477 21.6604
220067...................................................... 25.7414 26.4443 27.5405 26.5452
220068...................................................... 6.4548 * * 6.4548
220070...................................................... 19.7678 19.7528 20.9128 20.1099
220071...................................................... 24.6508 25.6184 27.4151 25.8715
220073...................................................... 25.8680 25.6025 26.1328 25.8683
220074...................................................... 24.0523 25.6390 24.3057 24.7411
220075...................................................... 21.5418 22.8057 22.5329 22.2794
220076...................................................... 24.7783 22.6668 23.2795 23.6106
220077...................................................... 24.8019 25.2646 26.1545 25.3933
220079...................................................... 21.0090 22.6256 22.0769 21.8560
220080...................................................... 20.5007 21.5238 22.1971 21.3825
220081...................................................... 25.3370 29.1726 29.6682 28.0686
220082...................................................... 20.0175 21.6726 22.1453 21.2140
220083...................................................... 23.0759 23.9156 22.5815 23.1732
220084...................................................... 24.6624 23.6641 25.3761 24.5459
220086...................................................... 30.4649 23.8705 26.7778 26.4452
220088...................................................... 23.3783 22.9067 23.4258 23.2384
220089...................................................... 21.7884 23.0965 25.4106 23.3099
220090...................................................... 21.6353 22.0041 23.3049 22.2774
220092...................................................... 17.0409 18.5239 24.7905 19.4783
220094...................................................... 21.9853 * * 21.9853
220095...................................................... 21.4468 21.4831 21.7851 21.5735
220098...................................................... 20.8596 21.5906 23.1547 21.8533
220100...................................................... 25.3484 25.7077 27.5841 26.2007
220101...................................................... 24.3260 25.9204 27.0711 25.7662
220104...................................................... 27.5297 28.0021 28.7258 28.0695
220105...................................................... 21.6873 21.4129 21.9185 21.6684
220106...................................................... 24.5518 25.6577 25.9277 25.3659
220107...................................................... 20.2719 * * 20.2719
220108...................................................... 22.6372 21.9115 23.4975 22.6709
220110...................................................... 29.1927 28.7071 29.1648 29.0217
220111...................................................... 23.0475 23.8066 24.7510 23.8707
220116...................................................... 24.9744 26.1662 32.0049 27.4579
220118...................................................... 30.5213 * * 30.5213
220119...................................................... 22.8586 23.3216 23.8785 23.3181
220123...................................................... 27.3063 25.8994 32.4678 28.6276
220126...................................................... 20.9557 22.5218 23.6045 22.3000
220128...................................................... 20.5636 * * 20.5636
220133...................................................... 35.2747 25.4596 29.3911 30.0324
220135...................................................... 25.0798 25.6522 28.3648 26.3313
220153...................................................... 23.8981 22.9592 * 23.4152
220154...................................................... 22.1261 22.4770 21.1563 22.0118
220163...................................................... 27.3527 29.1143 29.2299 28.5578
220171...................................................... 23.4340 24.5553 24.9261 24.3151
230001...................................................... 19.2015 19.8020 20.0438 19.6841
230002...................................................... 21.9058 22.7991 23.0439 22.5920
230003...................................................... 19.6118 19.8420 21.2215 20.2501
230004...................................................... 22.0310 23.1036 20.5005 21.8004
230005...................................................... 19.4040 18.5644 17.0943 18.3438
230006...................................................... 18.4681 19.1041 20.4978 19.3271
230007...................................................... 19.4339 15.5538 * 18.1334
230012...................................................... 18.6663 15.0803 * 16.5807
230013...................................................... 20.6322 20.8018 22.2211 21.1847
230015...................................................... 20.4264 20.1104 20.6464 20.3967
230017...................................................... 20.3975 22.2822 22.9755 21.8495
230019...................................................... 21.3222 22.2622 23.6674 22.4892
230020...................................................... 21.3206 22.1280 21.8526 21.7774
230021...................................................... 18.5670 18.9636 19.8256 19.1973
230022...................................................... 19.7598 18.8006 21.9129 20.1618
[[Page 39990]]
230024...................................................... 27.9551 23.7326 24.9664 25.4314
230027...................................................... 18.0285 14.6950 19.6393 17.2624
230029...................................................... 21.0636 19.4911 22.1782 20.9312
230030...................................................... 17.7040 18.3916 18.6406 18.2548
230031...................................................... 17.5352 19.3162 19.9465 18.8845
230032...................................................... 20.6821 21.8845 24.8930 22.4347
230034...................................................... 17.2302 19.0473 19.4366 18.6363
230035...................................................... 17.5607 17.5109 17.7490 17.6051
230036...................................................... 21.7565 23.2119 23.8398 22.9390
230037...................................................... 19.0688 20.4747 23.2751 20.8659
230038...................................................... 23.3876 23.5251 21.9692 22.9521
230040...................................................... 20.3897 21.4393 20.7841 20.8605
230041...................................................... 19.0278 20.3131 21.7364 20.3273
230042...................................................... 19.4937 22.1043 21.3870 21.0005
230046...................................................... 25.9482 25.5696 25.3206 25.6107
230047...................................................... 20.6379 21.5381 22.3595 21.5205
230053...................................................... 22.1781 25.4968 26.8917 24.7553
230054...................................................... 19.5427 20.6963 20.8014 20.3482
230055...................................................... 19.8381 20.7932 20.8492 20.4732
230056...................................................... 16.4101 16.0766 17.8091 16.7213
230058...................................................... 18.2349 20.4165 21.0303 19.9623
230059...................................................... 19.5098 19.9240 20.7092 20.0517
230060...................................................... 17.8716 19.8021 19.8987 19.1871
230062...................................................... 16.2952 17.1540 18.8039 17.3634
230063...................................................... 20.2211 20.4171 * 20.3143
230065...................................................... 21.1507 22.3459 22.7416 22.2057
230066...................................................... 21.5116 22.1768 23.0475 22.2618
230069...................................................... 21.7909 23.2076 24.2470 23.0592
230070...................................................... 20.0645 20.2505 21.5666 20.8098
230071...................................................... 22.1556 22.9052 23.1337 22.7304
230072...................................................... 20.4308 20.6944 20.4456 20.5245
230075...................................................... 19.4316 20.0545 22.5866 20.6203
230076...................................................... 23.8201 24.4547 24.7010 24.2886
230077...................................................... 20.3937 21.0178 20.2823 20.5602
230078...................................................... 16.2486 17.5577 17.9868 17.2435
230080...................................................... 18.9084 19.7687 20.2104 19.6745
230081...................................................... 17.9510 19.0345 19.0199 18.6644
230082...................................................... 17.7417 18.2992 19.0419 18.3501
230085...................................................... 17.5447 20.2096 23.4996 20.3924
230086...................................................... 16.9754 18.9420 20.1730 18.6767
230087...................................................... 15.7694 18.9034 19.9700 18.0112
230089...................................................... 21.3914 23.9100 22.6994 22.6194
230092...................................................... 18.9567 20.0145 20.7738 19.9304
230093...................................................... 20.1928 20.4655 20.6314 20.4325
230095...................................................... 16.7830 17.3313 17.6444 17.2565
230096...................................................... 22.5613 22.8410 22.7785 22.7256
230097...................................................... 20.0960 21.2854 21.1254 20.8481
230099...................................................... 20.2529 21.1933 21.7513 21.0709
230100...................................................... 13.1107 17.1336 17.3842 16.0298
230101...................................................... 18.6098 20.0932 20.5315 19.7445
230103...................................................... 19.6014 22.7696 11.3429 17.7532
230104...................................................... 23.4703 23.1457 24.1238 23.5809
230105...................................................... 20.8765 21.5210 22.6098 21.6727
230106...................................................... 18.3508 20.7997 21.6825 20.2936
230107...................................................... 14.6673 16.5966 17.1386 15.9949
230108...................................................... 17.4231 18.8631 20.3437 18.8600
230110...................................................... 17.8017 18.9825 19.7262 18.8384
230113...................................................... 11.1676 14.9411 * 12.8926
230115...................................................... 16.4728 18.4050 19.6281 18.1783
230116...................................................... 16.3563 16.5419 14.5692 15.7763
230117...................................................... 23.9389 25.9318 25.6797 25.1927
230118...................................................... 21.7089 21.3028 20.6797 21.2068
230119...................................................... 23.9568 21.1918 22.6555 22.5908
[[Page 39991]]
230120...................................................... 19.6400 18.5264 20.3306 19.4421
230121...................................................... 20.0786 20.3158 21.3342 20.5789
230122...................................................... 18.0903 20.9078 * 19.5648
230124...................................................... 18.8938 20.3608 18.9981 19.3961
230125...................................................... 15.3497 * * 15.3497
230128...................................................... 23.5787 24.9081 24.0724 24.1436
230130...................................................... 22.5204 23.5170 22.1775 22.7280
230132...................................................... 26.1727 26.6386 26.1946 26.3381
230133...................................................... 17.5688 17.6894 17.1058 17.4473
230134...................................................... 15.3248 * * 15.3248
230135...................................................... 22.7401 22.5258 20.5637 22.0738
230137...................................................... 18.3431 19.1813 * 18.7522
230141...................................................... 23.0496 22.1299 22.4570 22.5592
230142...................................................... 20.1242 22.2940 23.5621 21.8277
230143...................................................... 16.4468 16.3043 16.7948 16.5112
230144...................................................... 20.9906 22.1108 23.4237 22.1285
230145...................................................... 16.5986 20.2542 19.2638 18.8354
230146...................................................... 18.6293 20.5044 21.2260 20.1486
230147...................................................... 20.5144 21.8496 23.2755 21.8616
230149...................................................... 14.1740 20.7691 18.8005 17.7545
230151...................................................... 20.8884 22.1713 23.3967 22.0865
230153...................................................... 17.3280 19.5633 18.7403 18.5291
230154...................................................... 14.5846 15.4456 15.4362 15.1635
230155...................................................... 16.9857 17.2076 20.5409 18.1875
230156...................................................... 23.6126 24.7587 25.6228 24.6740
230157...................................................... 19.7197 20.3667 17.3571 19.2380
230159...................................................... 18.8426 20.0749 * 19.3914
230162...................................................... 17.7689 21.4636 21.7148 20.3064
230165...................................................... 23.3147 23.0106 23.8881 23.4094
230167...................................................... 20.3210 21.5048 22.9745 21.5685
230169...................................................... 22.8606 23.0652 24.3874 23.4345
230171...................................................... 14.9595 13.3863 17.1282 15.0778
230172...................................................... 20.2191 20.6417 21.4675 20.7898
230174...................................................... 20.8542 23.0272 22.7304 22.1820
230175...................................................... 21.8097 16.8909 * 19.0428
230176...................................................... 21.8618 22.7772 23.8204 22.8229
230178...................................................... 16.0818 16.9156 17.3030 16.7485
230180...................................................... 15.4837 15.8769 18.5744 16.6297
230184...................................................... 17.2928 19.0604 19.7717 18.6605
230186...................................................... * 19.5337 15.7837 17.6806
230188...................................................... 15.5563 15.7112 16.2975 15.8821
230189...................................................... 15.9089 16.6838 17.9218 16.8493
230190...................................................... 23.7134 26.8196 26.4687 25.7543
230191...................................................... 17.1221 19.0013 18.4861 18.1647
230193...................................................... 20.1805 19.7066 19.8287 19.9318
230195...................................................... 22.3745 21.7775 22.9228 22.3732
230197...................................................... 21.6184 24.0184 24.0854 23.1281
230199...................................................... 18.4012 19.4451 20.6580 19.5586
230201...................................................... 15.3206 17.2141 18.0787 16.9556
230204...................................................... 22.9506 25.4181 23.4966 23.9387
230205...................................................... 13.8861 14.3788 15.9314 14.6555
230207...................................................... 20.3538 20.6375 21.2483 20.7256
230208...................................................... 17.1501 16.0733 16.7454 16.6668
230211...................................................... 17.5087 18.6744 21.8581 19.0214
230212...................................................... 22.1370 23.3021 24.2611 23.2193
230213...................................................... 15.3159 15.1908 15.5469 15.3407
230216...................................................... 19.5921 20.3359 21.0710 20.3422
230217...................................................... 20.9510 21.2707 22.2698 21.4978
230219...................................................... 20.7018 19.1549 20.0442 19.9745
230221...................................................... 21.5000 * * 21.5000
230222...................................................... 20.8430 22.1785 21.9711 21.6725
230223...................................................... 21.4990 21.1528 22.6887 21.7715
230227...................................................... 21.3801 23.7259 22.3155 22.4395
[[Page 39992]]
230230...................................................... 22.5346 22.2385 22.3097 22.3587
230232...................................................... 12.6373 * * 12.6373
230235...................................................... 15.9466 16.8684 17.7197 16.8275
230236...................................................... 23.2178 24.3835 25.9676 24.5556
230239...................................................... 19.2349 18.0942 17.8168 18.3625
230241...................................................... 18.8451 19.1000 20.7297 19.5624
230244...................................................... 21.0758 21.7413 22.2697 21.6892
230253...................................................... 21.9497 20.5945 21.0433 21.1989
230254...................................................... 21.2786 21.9402 22.6335 21.9383
230257...................................................... 20.4721 19.6982 21.3880 20.5021
230259...................................................... 21.1519 22.2393 22.3969 21.9147
230264...................................................... 15.1818 17.1319 17.4864 16.5360
230269...................................................... 22.8138 23.3105 24.0992 23.4229
230270...................................................... 20.0803 22.6187 22.5985 21.6440
230273...................................................... 23.4000 22.9199 22.8715 23.0744
230275...................................................... 17.5975 17.7487 20.8985 18.2554
230276...................................................... 18.5750 21.3722 25.8709 21.5415
230277...................................................... 22.5012 23.1456 23.9771 23.2364
230278...................................................... 16.6645 18.2110 * 17.3814
230279...................................................... 16.0437 17.6973 17.8074 17.2147
230280...................................................... 14.2249 15.6654 18.3497 15.8025
230283...................................................... * 27.9480 22.5082 24.9202
240001...................................................... 22.8480 24.6207 25.6936 24.3586
240002...................................................... 23.0240 22.7981 23.2307 23.0178
240004...................................................... 23.9195 25.1908 24.4030 24.5010
240005...................................................... 16.9775 17.9563 20.3193 18.3770
240006...................................................... 27.1133 25.1602 23.0715 24.9568
240007...................................................... 16.9802 17.7625 19.0850 17.9138
240008...................................................... 21.8068 20.2158 23.3783 21.6628
240009...................................................... 16.6910 16.8965 17.1187 16.9211
240010...................................................... 23.6323 23.6477 25.4752 24.2587
240011...................................................... 18.9559 20.5192 21.5875 20.3298
240013...................................................... 18.9705 20.3282 21.7544 20.2656
240014...................................................... 21.8560 23.0025 24.2610 23.0452
240016...................................................... 19.8624 20.4017 22.2011 20.8274
240017...................................................... 17.2325 18.3585 18.9272 18.1627
240018...................................................... 19.0671 20.8501 18.4268 19.4219
240019...................................................... 20.9869 22.1501 23.1477 22.1062
240020...................................................... 19.5727 21.1937 20.8849 20.5389
240021...................................................... 17.3968 18.7515 20.1457 18.6569
240022...................................................... 19.1554 21.7889 21.3234 20.7594
240023...................................................... 20.3923 21.5087 22.8224 21.4999
240025...................................................... 17.2464 18.8345 20.0308 18.7384
240027...................................................... 16.2531 19.1017 16.7758 17.3367
240028...................................................... 19.3781 19.7918 25.1934 21.5071
240029...................................................... 17.9880 21.1329 20.0164 19.6781
240030...................................................... 18.4358 18.8547 20.1653 19.1669
240031...................................................... 18.0652 18.1566 19.3983 18.5009
240036...................................................... 20.3270 22.2460 22.1721 21.6421
240037...................................................... 18.4564 19.2345 20.1195 19.3188
240038...................................................... 26.3539 25.3061 24.3957 25.3169
240040...................................................... 19.9022 20.4813 23.1352 21.0482
240041...................................................... 19.2127 19.2864 21.8655 20.0389
240043...................................................... 17.3064 17.7335 16.9859 17.3013
240044...................................................... 18.9217 18.8411 20.3339 19.3394
240045...................................................... 20.9873 21.1396 24.1557 22.0716
240047...................................................... 21.8576 22.6152 23.8098 22.7467
240048...................................................... 23.3110 * * 23.3110
240049...................................................... 22.1345 * * 22.1345
240050...................................................... 24.5027 25.2983 21.6499 22.6550
240051...................................................... 18.2287 19.9195 22.5855 20.1307
240052...................................................... 19.2190 20.7749 * 19.9948
240053...................................................... 21.1987 22.9611 23.8693 22.7802
[[Page 39993]]
240056...................................................... 22.2927 23.4226 23.7139 23.1375
240057...................................................... 23.2377 24.2159 24.8686 24.1392
240058...................................................... 14.9141 14.9697 18.4009 15.9713
240059...................................................... 21.9575 23.6215 23.7808 23.1092
240061...................................................... 25.5581 27.2603 25.9951 26.2655
240063...................................................... 23.5426 23.7866 24.4031 23.9101
240064...................................................... 20.7602 23.2860 22.8578 22.2645
240065...................................................... 12.5547 12.7867 14.8734 13.4307
240066...................................................... 22.0542 23.0698 24.1143 23.1023
240069...................................................... 19.1834 19.8282 21.7991 20.2573
240071...................................................... 19.1913 20.2101 21.2463 20.2337
240072...................................................... 18.0015 21.1824 20.9529 20.0007
240073...................................................... 15.6318 16.0840 17.3559 16.3592
240075...................................................... 21.1934 21.2654 21.3357 21.2661
240076...................................................... 21.0702 21.8795 22.3280 21.7859
240077...................................................... 14.9493 15.3794 20.3445 16.8827
240078...................................................... 22.7122 23.9150 25.1082 23.9382
240079...................................................... 17.8206 18.4338 18.8345 18.3648
240080...................................................... 23.7286 24.3399 25.5619 24.7160
240082...................................................... 18.0272 18.3555 18.7995 18.3952
240083...................................................... 19.2922 19.7637 21.0317 20.0094
240084...................................................... 19.6078 19.4739 21.7421 20.2965
240085...................................................... 18.0214 22.5736 20.9778 20.5540
240086...................................................... 15.3302 16.9392 18.1401 16.9654
240087...................................................... 17.0624 18.8352 21.3323 19.0315
240088...................................................... 21.0202 21.6858 23.1056 21.8928
240089...................................................... 18.4171 20.7239 21.1989 20.0227
240090...................................................... 18.0490 19.2968 19.2166 18.8331
240093...................................................... 18.6788 18.7092 20.2400 19.2268
240094...................................................... 20.5705 20.9446 22.0247 21.2053
240096...................................................... 18.3365 20.1644 21.0417 19.7961
240097...................................................... 23.6230 24.2662 27.9496 25.1295
240098...................................................... 20.6036 21.3467 24.2296 22.0643
240099...................................................... 14.3759 14.4649 15.4964 14.7485
240100...................................................... 19.1921 20.8302 20.8325 20.3051
240101...................................................... 17.7478 19.2120 19.9837 18.9205
240102...................................................... 15.5644 14.6067 16.3659 15.5008
240103...................................................... 16.8805 19.1540 18.7510 18.2532
240104...................................................... 24.0175 23.2178 23.5351 23.5902
240105...................................................... 14.7904 14.3965 * 14.6094
240106...................................................... 23.7818 23.5148 23.5005 23.6022
240107...................................................... 19.0299 20.3983 20.9004 20.0558
240108...................................................... 16.4605 15.3547 18.2427 16.5529
240109...................................................... 13.1537 13.5537 16.3216 14.2359
240110...................................................... 17.2834 19.4828 21.0277 19.2199
240111...................................................... 17.0408 17.2100 17.8617 17.3567
240112...................................................... 15.3246 15.8350 16.6244 15.9308
240114...................................................... 15.4919 16.2505 17.3682 16.3794
240115...................................................... 22.1575 23.7765 23.8675 23.3187
240116...................................................... 15.1757 16.6731 18.3520 16.6014
240117...................................................... 17.5676 18.0636 17.9941 17.8845
240119...................................................... 22.4981 20.6126 21.8289 21.5894
240121...................................................... 21.3747 23.4018 22.2266 22.3266
240122...................................................... 18.0396 19.1811 21.2876 19.5090
240123...................................................... 15.5968 16.5098 18.3941 16.7420
240124...................................................... 19.0505 19.4400 20.4728 19.6473
240125...................................................... 13.1505 12.3627 14.9708 13.5694
240127...................................................... 14.7670 15.8966 17.9724 16.1476
240128...................................................... 16.0759 17.2513 16.3608 16.5520
240129...................................................... 15.4226 14.4212 16.5209 15.4258
240130...................................................... 15.6477 14.9399 16.4271 15.6650
240132...................................................... 24.4998 23.0669 23.1452 23.5239
240133...................................................... 18.5216 19.2126 19.5293 19.1081
[[Page 39994]]
240135...................................................... 13.6014 14.3069 15.7015 14.4270
240137...................................................... 19.1770 20.3750 21.5073 20.3195
240138...................................................... 13.7359 15.2062 16.7332 15.1922
240139...................................................... 17.0163 20.8053 20.5496 19.6213
240141...................................................... 21.9909 23.8066 23.1009 22.9648
240142...................................................... 20.6139 25.2770 29.2238 24.5024
240143...................................................... 14.2790 16.6172 20.4266 16.9078
240144...................................................... 15.8710 18.2604 21.4469 18.2664
240145...................................................... 14.9997 17.2778 19.0689 17.4197
240146...................................................... 16.7496 16.0652 16.5412 16.4544
240148...................................................... 11.3388 18.8779 19.5204 16.6060
240150...................................................... 12.8255 13.8786 20.8331 15.4453
240152...................................................... 20.2020 21.1678 22.4744 21.2973
240153...................................................... 15.6079 16.5412 19.3336 17.0363
240154...................................................... 17.0625 17.5769 21.5052 18.6158
240155...................................................... 20.4189 19.8762 20.9385 20.4180
240157...................................................... 14.6914 17.4168 13.7309 15.3007
240160...................................................... 16.6034 15.9492 15.9014 16.1454
240161...................................................... 15.4160 15.7996 16.8809 15.9681
240162...................................................... 19.0404 16.6292 19.1542 18.1964
240163...................................................... 17.8714 18.8320 20.4760 18.9698
240166...................................................... 16.3907 17.3233 19.4131 17.7688
240169...................................................... 18.6155 16.6725 16.3958 17.2174
240170...................................................... 17.6501 18.8762 20.3779 18.9004
240171...................................................... 16.7237 17.2886 18.5172 17.5402
240172...................................................... 16.0711 18.2852 20.8606 18.2323
240173...................................................... 16.7411 17.2655 18.5187 17.5027
240179...................................................... 16.6464 17.5116 20.4004 18.1225
240184...................................................... 14.3996 15.3793 16.8917 15.4746
240187...................................................... 17.5154 19.9230 21.2736 19.5789
240193...................................................... 16.3004 17.8226 18.4664 17.4827
240196...................................................... 23.2666 24.3472 25.3479 24.3358
240200...................................................... 14.7295 14.3415 14.9076 14.6539
240207...................................................... 23.3339 24.1127 25.2814 24.2879
240210...................................................... 23.8391 24.2218 24.5664 24.2274
240211...................................................... 20.5548 19.7399 30.6260 22.1746
250001...................................................... 18.1407 18.4233 19.2756 18.6319
250002...................................................... 15.6036 17.2501 18.6938 17.1218
250003...................................................... 15.6560 17.6539 16.7570 16.6622
250004...................................................... 17.1177 17.8868 18.3860 17.7913
250005...................................................... 12.0032 12.5993 12.5834 12.3909
250006...................................................... 15.7036 16.9048 17.5192 16.6995
250007...................................................... 19.1555 19.2913 19.7562 19.3984
250008...................................................... 13.3179 14.1760 15.8506 14.4224
250009...................................................... 16.1847 18.5610 17.7283 17.5396
250010...................................................... 13.3372 13.3905 14.6101 13.7324
250012...................................................... 18.4756 14.1623 16.7579 16.4800
250015...................................................... 11.0747 13.5274 11.7249 11.9737
250017...................................................... 17.3006 17.9410 20.5976 18.5334
250018...................................................... 13.4707 11.9311 13.1687 12.7895
250019...................................................... 17.1501 16.7425 18.0956 17.3536
250020...................................................... 14.0618 13.4476 16.2698 14.4562
250021...................................................... 9.0772 9.4318 10.5844 9.6552
250023...................................................... 13.5440 13.9116 12.3434 13.2963
250024...................................................... 11.5940 12.7127 12.9899 12.4525
250025...................................................... 17.8890 19.0390 20.3625 19.2022
250027...................................................... 12.4241 14.9519 14.5445 13.9032
250029...................................................... 14.8456 16.4834 16.0682 15.8412
250030...................................................... 13.6277 17.3636 26.6173 19.2750
250031...................................................... 18.7663 17.9715 18.3825 18.3676
250032...................................................... 17.2983 17.1339 17.5957 17.3467
250033...................................................... 15.7646 17.8257 15.0941 16.2509
250034...................................................... 18.1269 16.6988 17.0399 17.2230
[[Page 39995]]
250035...................................................... 17.4148 15.2353 16.8349 16.3942
250036...................................................... 13.7928 15.8445 16.1913 15.3676
250037...................................................... 10.3212 15.4325 12.7156 12.4979
250038...................................................... 13.6207 16.8454 17.7019 16.0182
250039...................................................... 16.5105 14.1556 15.1409 15.2552
250040...................................................... 15.6367 17.3430 18.3364 17.1495
250042...................................................... 16.4728 16.3867 17.6531 16.8406
250043...................................................... 13.6492 16.0729 16.6500 15.4718
250044...................................................... 16.7462 16.1218 16.7321 16.5323
250045...................................................... 19.4788 22.0839 21.8988 21.2480
250047...................................................... 12.0953 13.3706 14.7461 13.3242
250048...................................................... 15.7073 16.8932 17.6649 16.7793
250049...................................................... 10.7578 11.6715 12.1635 11.5642
250050...................................................... 13.9220 14.3949 15.1159 14.4819
250051...................................................... 9.6017 9.3464 10.4900 9.8032
250057...................................................... 14.2863 15.9237 16.1838 15.4582
250058...................................................... 15.4206 15.5327 15.7197 15.5555
250059...................................................... 14.2997 16.2845 16.6494 15.7755
250060...................................................... 7.9882 13.0301 16.1804 11.2768
250061...................................................... 13.9655 11.0308 11.5108 11.9846
250063...................................................... 14.9743 13.2540 13.3092 13.7869
250065...................................................... 12.6803 12.8853 13.6904 13.0682
250066...................................................... 14.3274 15.6760 16.1742 15.4025
250067...................................................... 15.2871 16.4120 16.8522 16.2039
250068...................................................... 11.4272 13.6768 13.4127 12.8087
250069...................................................... 15.7653 17.8960 16.8980 16.8834
250071...................................................... 11.2079 14.3781 12.3488 12.5425
250072...................................................... 16.9263 18.2218 18.9487 18.0776
250076...................................................... * 10.5098 * 10.5098
250077...................................................... 11.4135 12.2564 13.7404 12.5026
250078...................................................... 15.4571 15.6336 15.9739 15.6895
250079...................................................... 19.0587 16.2712 16.5835 17.1998
250081...................................................... 16.1412 17.3325 19.0358 17.4600
250082...................................................... 14.0249 16.0975 17.1427 15.7611
250083...................................................... 9.2019 14.2634 16.6065 13.1746
250084...................................................... 19.7390 17.0189 20.6429 19.0165
250085...................................................... 13.8487 14.3797 15.4477 14.5716
250088...................................................... 16.7514 17.8674 18.2736 17.6409
250089...................................................... 13.0481 13.4238 14.3027 13.5884
250093...................................................... 15.0918 15.2044 16.1506 15.4926
250094...................................................... 17.8539 18.0852 18.5063 18.1422
250095...................................................... 16.3574 17.0039 17.4217 16.9079
250096...................................................... 17.0713 19.0688 19.0584 18.3546
250097...................................................... 18.4099 16.9905 15.5741 16.9320
250098...................................................... 14.3017 13.1341 18.3874 15.0909
250099...................................................... 14.4142 14.8528 15.1265 14.8018
250100...................................................... 16.6033 17.1682 17.8688 17.2128
250101...................................................... 16.3083 18.4685 17.7194 17.5079
250102...................................................... 20.0190 23.9329 18.9348 20.8793
250104...................................................... 17.5421 18.2502 18.7651 18.1832
250105...................................................... 14.5986 14.5401 15.5133 14.8921
250107...................................................... 13.6296 15.1496 15.0737 14.6455
250109...................................................... 14.5496 22.1551 21.3867 18.8951
250112...................................................... 14.2023 15.5610 16.3640 15.3179
250117...................................................... 14.5171 16.1225 16.9787 15.9014
250119...................................................... 12.7379 15.2199 16.1218 14.6728
250120...................................................... 14.4126 15.3433 16.7182 15.4420
250122...................................................... 17.7079 18.9417 19.2990 18.6619
250123...................................................... 17.4068 18.8690 18.7863 18.3698
250124...................................................... 12.6677 13.1823 13.2490 13.0310
250125...................................................... 14.4867 20.8895 21.2660 18.4338
250126...................................................... 14.7083 18.2355 21.9101 17.8900
250128...................................................... 12.9968 14.0048 16.1418 14.4375
[[Page 39996]]
250131...................................................... 10.2765 12.6056 12.4557 11.6657
250134...................................................... 17.9755 17.0671 18.5142 17.8554
250136...................................................... 18.0538 18.9689 21.3497 19.3579
250138...................................................... 17.5999 18.4028 20.4550 18.6918
250141...................................................... 17.1247 19.0113 19.6692 18.6505
250145...................................................... 11.4047 10.2507 11.2120 10.9506
250146...................................................... 13.2763 14.4924 14.7781 14.1955
250148...................................................... 14.8234 18.0980 19.4233 17.4956
250149...................................................... 12.9840 12.9569 15.2318 13.7102
250150...................................................... * * 21.8599 21.8599
260001...................................................... 17.5520 18.0971 20.1560 18.5941
260002...................................................... 20.5878 22.1183 21.6597 21.4585
260003...................................................... 14.3537 14.6553 15.4482 14.8108
260004...................................................... 13.7528 13.0133 13.7035 13.4793
260005...................................................... 19.7058 19.5554 23.9681 21.0036
260006...................................................... 18.9408 19.7467 20.0994 19.6144
260008...................................................... 16.2451 13.8495 16.8893 15.5719
260009...................................................... 17.9364 18.5080 18.2863 18.2469
260011...................................................... 18.3378 19.1027 19.5059 18.9819
260012...................................................... 14.4594 14.3645 17.1662 15.3316
260013...................................................... 15.5388 15.9884 16.1825 15.8932
260015...................................................... 21.3327 16.5822 17.8817 18.4578
260017...................................................... 15.8013 16.7916 16.9914 16.5434
260018...................................................... 12.2293 12.0060 12.5301 12.2688
260019...................................................... 23.6727 18.6113 * 20.6992
260020...................................................... 21.8585 20.5142 20.2241 20.8205
260021...................................................... 17.5694 22.1017 21.6237 20.1803
260022...................................................... 19.3454 17.2462 17.7772 17.8898
260023...................................................... 15.8235 16.4705 17.8649 16.6827
260024...................................................... 13.4737 15.2356 15.7815 14.8371
260025...................................................... 14.9377 15.4935 17.0965 15.8836
260027...................................................... 21.0084 21.2977 22.0362 21.4252
260029...................................................... 17.4744 19.7484 21.1858 19.3784
260030...................................................... 11.2434 12.5118 11.9215 11.8847
260031...................................................... 18.3039 19.4921 19.7249 19.1438
260032...................................................... 20.8097 20.1988 19.6728 20.2222
260034...................................................... 17.8986 17.4233 20.4902 18.5746
260035...................................................... 12.5886 13.1065 13.0071 12.9052
260036...................................................... 18.3128 16.7430 18.8104 17.9282
260039...................................................... 14.1980 14.1866 14.6644 14.3527
260040...................................................... 15.3853 17.3099 18.0140 16.9033
260042...................................................... 17.4459 18.7567 18.7514 18.2697
260044...................................................... 17.1177 15.9927 15.9206 16.3491
260047...................................................... 17.2768 19.0112 19.2247 18.5386
260048...................................................... 21.4309 20.0885 21.0602 20.8622
260050...................................................... 18.7366 15.6908 16.8520 17.0991
260052...................................................... 17.7502 18.0553 18.0914 17.9657
260053...................................................... 12.0098 15.2236 16.5166 14.4005
260054...................................................... 17.3708 20.0199 20.6242 19.2873
260055...................................................... 13.7961 12.0118 15.4214 13.6790
260057...................................................... 15.3276 17.4636 19.7144 17.7259
260059...................................................... 15.7887 16.1000 17.0546 16.3478
260061...................................................... 15.0099 14.7175 15.7112 15.1405
260062...................................................... 20.2655 20.1477 21.3138 20.5946
260063...................................................... 16.8474 18.2309 18.8973 17.9893
260064...................................................... 16.5033 16.5934 17.8033 16.9429
260065...................................................... 18.4654 19.4382 20.0975 19.3238
260066...................................................... 14.4163 14.9640 15.3460 14.8934
260067...................................................... 12.1588 14.2249 15.1837 13.8617
260068...................................................... 19.8261 20.2418 19.4240 19.8242
260070...................................................... 21.6873 * 13.9510 17.3672
260073...................................................... 13.0075 14.2550 15.9182 14.4333
260074...................................................... 15.4480 19.0350 19.8915 18.1123
[[Page 39997]]
260077...................................................... 18.2594 18.6473 19.4482 18.8035
260078...................................................... 15.4754 15.6381 14.9463 15.3700
260079...................................................... 14.8281 14.2985 16.1453 15.0169
260080...................................................... 12.5631 13.5384 14.6832 13.5392
260081...................................................... 18.9629 21.0151 20.3053 20.0653
260082...................................................... 15.7880 15.9407 15.9858 15.9090
260085...................................................... 19.5153 20.4669 20.7051 20.2110
260086...................................................... 14.8730 14.3164 15.2927 14.8291
260091...................................................... 19.6081 19.9987 21.5464 20.5925
260094...................................................... 15.8705 18.0085 18.5395 17.5281
260095...................................................... 19.7672 19.6944 20.7292 20.0618
260096...................................................... 21.7176 23.0282 22.5972 22.4661
260097...................................................... 15.7899 16.5582 19.0632 17.1704
260100...................................................... 15.7324 15.7047 16.6523 16.0345
260102...................................................... 16.3653 20.1264 20.6361 18.8983
260103...................................................... 17.3541 18.5957 19.7146 18.4987
260104...................................................... 19.1158 21.0138 20.3176 20.0928
260105...................................................... 20.8006 24.7223 24.8181 23.3052
260107...................................................... 18.4618 19.8422 20.4269 19.5069
260108...................................................... 19.2422 19.4609 20.0034 19.5906
260109...................................................... 13.4400 13.9129 14.8181 14.0725
260110...................................................... 16.9952 17.8375 18.3227 17.7209
260113...................................................... 14.8968 14.6756 16.2223 15.2316
260115...................................................... 17.8971 19.2259 17.4698 18.2033
260116...................................................... 14.5715 16.2774 14.9812 15.2548
260119...................................................... 16.2000 16.8836 17.2942 16.7641
260120...................................................... 17.1269 16.3755 16.4904 16.6414
260122...................................................... 14.5390 14.9697 16.0931 15.2238
260123...................................................... 13.9960 14.6444 14.6822 14.4496
260127...................................................... 15.9481 18.3572 18.4026 17.5109
260128...................................................... 11.2705 13.0481 12.6414 12.2813
260129...................................................... 14.6353 * * 14.6353
260131...................................................... 19.7491 17.7686 18.4154 18.5978
260134...................................................... 16.5834 16.2832 17.5127 16.7877
260137...................................................... 15.2169 17.9531 19.4697 17.5188
260138...................................................... 21.3885 22.6491 23.2364 22.4440
260141...................................................... 17.9598 19.1580 19.1893 18.7555
260142...................................................... 16.0299 17.1248 17.3084 16.7937
260143...................................................... 11.9389 12.7867 13.9040 12.7859
260147...................................................... 13.6568 14.0778 14.7769 14.1672
260148...................................................... 10.3383 11.8674 11.3524 11.2072
260158...................................................... 12.4020 12.3005 12.7699 12.4966
260159...................................................... 18.2232 20.3177 19.7951 19.3893
260160...................................................... 16.1922 15.8394 16.5792 16.2009
260162...................................................... 20.7103 19.5655 21.4099 20.5728
260163...................................................... 14.8051 16.4245 15.8593 15.6940
260164...................................................... 14.3089 14.9372 15.1211 14.8191
260166...................................................... 19.5343 20.1025 21.1224 20.2675
260172...................................................... 12.4851 15.4163 16.0772 14.6285
260173...................................................... 11.9777 12.8523 14.2090 13.1471
260175...................................................... 16.2940 16.9023 17.5625 16.9246
260176...................................................... 19.5449 26.8712 21.6044 22.7500
260177...................................................... 20.7457 21.2578 21.9014 21.3180
260178...................................................... 21.4080 19.6638 20.2796 20.4480
260179...................................................... 20.7397 21.4906 22.7185 21.6624
260180...................................................... 18.5398 19.5819 18.9881 19.0361
260183...................................................... 20.1940 20.0712 21.3175 20.5306
260186...................................................... 18.0588 19.3238 19.6026 19.0698
260188...................................................... 18.5772 20.6388 22.5060 20.5016
260189...................................................... 10.7518 11.3004 16.4233 12.7425
260190...................................................... 18.1639 18.5168 19.3419 18.6978
260191...................................................... 19.3386 17.9812 18.1604 18.4767
260193...................................................... 20.5055 21.1588 20.2577 20.6284
[[Page 39998]]
260195...................................................... 15.9518 17.7237 19.7068 17.8042
260197...................................................... 16.4605 19.2840 20.5453 18.3884
260198...................................................... 17.6381 11.9751 19.7552 15.6949
260200...................................................... 18.8755 20.5339 20.6888 20.0233
260205...................................................... * 17.6210 * 17.6210
270002...................................................... 17.1866 28.9959 19.2387 20.5385
270003...................................................... 22.1299 22.0995 22.5019 22.2424
270004...................................................... 21.3442 19.6292 19.4834 20.1660
270006...................................................... 16.1872 16.0238 17.0715 16.3653
270007...................................................... 13.1679 11.3143 13.8824 12.6774
270009...................................................... 17.7016 17.2292 20.8238 18.5056
270011...................................................... 19.8229 20.2669 21.1653 20.3748
270012...................................................... 22.8770 19.7346 19.7878 20.8557
270013...................................................... 20.4012 * * 20.4012
270014...................................................... 18.5595 19.0872 19.9859 19.2205
270016...................................................... 19.7675 19.6717 18.6149 19.4350
270017...................................................... 19.5798 21.0800 20.0152 20.2382
270019...................................................... 12.7812 18.1099 15.4128 15.4635
270021...................................................... 16.6541 17.1787 16.9457 16.9258
270023...................................................... 20.3641 22.2639 22.7181 21.7139
270026...................................................... 15.6381 17.5102 18.0568 17.0775
270027...................................................... 9.7758 13.1392 17.2091 12.8885
270028...................................................... 17.2132 21.1492 19.1177 19.1160
270029...................................................... 17.8852 16.5666 17.3710 17.2639
270032...................................................... 17.0285 17.7393 18.7811 17.8749
270033...................................................... 16.4554 16.9602 18.4876 17.2764
270035...................................................... 17.6482 16.8295 16.4302 16.9974
270036...................................................... 14.0815 14.2537 16.8552 14.8821
270039...................................................... 15.3501 15.9368 19.6796 16.7774
270040...................................................... 19.1901 18.8145 20.1242 19.3585
270041...................................................... 16.7791 19.0327 25.8153 19.7981
270044...................................................... 13.4559 16.7710 17.5137 15.8620
270046...................................................... 17.1048 * * 17.1048
270048...................................................... 15.8403 17.0154 18.0666 16.8972
270049...................................................... 21.1670 22.2444 22.2540 21.8899
270050...................................................... 18.0448 16.7110 19.9356 18.1546
270051...................................................... 18.9468 20.2735 20.1950 19.8100
270052...................................................... 14.8042 14.4773 14.7009 14.6552
270057...................................................... 20.0080 21.1317 20.6714 20.6119
270058...................................................... 14.0669 14.7481 16.1412 14.9510
270059...................................................... 15.5957 14.7530 19.1808 16.3576
270060...................................................... 14.0212 15.2727 20.4148 16.5316
270063...................................................... 14.2287 12.6108 15.1049 13.8837
270073...................................................... 15.5281 14.4569 16.1937 15.3359
270079...................................................... 15.0277 15.6873 16.7048 15.7603
270080...................................................... 14.0437 16.3171 15.0705 15.0926
270081...................................................... 15.5207 15.6262 16.7389 15.9424
270082...................................................... 16.1280 17.3443 23.1245 18.7794
270083...................................................... 20.8231 18.4432 17.8554 18.9597
270084...................................................... 16.2075 16.6243 16.2958 16.3734
280001...................................................... 17.8928 17.3541 18.1831 17.7825
280003...................................................... 21.9957 22.3179 23.0213 22.4564
280005...................................................... 18.7477 19.2405 23.6949 20.6104
280009...................................................... 18.7541 19.8145 20.9643 19.8453
280010...................................................... 16.5417 17.4859 20.0462 17.5272
280011...................................................... 13.9627 15.8573 15.9614 15.3328
280012...................................................... 16.4079 * * 16.4079
280013...................................................... 22.1767 22.8063 22.5163 22.5039
280014...................................................... 15.2414 15.9596 16.8368 15.9667
280015...................................................... 14.6353 17.0281 16.6939 16.1405
280017...................................................... 14.1897 14.2059 13.9939 14.1278
280018...................................................... 14.8492 15.1328 15.4496 15.1512
280020...................................................... 19.3963 19.9667 21.2467 20.2637
[[Page 39999]]
280021...................................................... 16.6949 17.1048 17.6345 17.1389
280022...................................................... 15.7059 16.7179 16.8184 16.3693
280023...................................................... 21.2387 25.8494 22.3433 23.0540
280024...................................................... 13.9115 14.2186 15.0380 14.3613
280025...................................................... 14.2701 15.5850 21.4764 16.6875
280026...................................................... 16.0599 16.6861 16.5851 16.4520
280028...................................................... 15.8871 17.3176 18.0793 17.1201
280029...................................................... 19.0519 23.1292 24.4359 21.9196
280030...................................................... 28.7091 24.5366 24.7723 25.8891
280031...................................................... 13.2242 13.5654 9.6321 12.1542
280032...................................................... 19.3884 18.8964 19.1191 19.1301
280033...................................................... 14.9334 15.7583 17.4745 16.1329
280034...................................................... 15.2821 * * 15.2821
280035...................................................... 15.3304 15.9170 16.6872 15.8969
280037...................................................... 16.1684 16.7952 17.1064 16.6926
280038...................................................... 16.4685 17.0878 18.2503 17.2635
280039...................................................... 15.1916 16.0442 16.1587 15.8239
280040...................................................... 18.9717 19.5333 20.9896 19.8846
280041...................................................... 13.3901 16.4083 16.5503 15.4920
280042...................................................... 15.3029 16.1191 16.6239 16.0122
280043...................................................... 15.7858 16.6570 17.5937 16.7160
280045...................................................... 14.2741 16.9048 15.7630 15.6286
280046...................................................... 13.7155 17.9221 17.3214 16.1724
280047...................................................... 18.3743 18.3407 17.4735 18.0424
280048...................................................... 14.0702 15.8723 15.8100 15.1939
280049...................................................... 15.6343 18.3605 18.4365 17.4677
280050...................................................... 15.3413 16.6432 20.0379 17.6064
280051...................................................... 15.8504 15.6336 17.1942 16.1502
280052...................................................... 13.6489 14.0819 14.1201 13.9629
280054...................................................... 17.5819 18.7992 18.7575 18.3765
280055...................................................... 12.9933 13.5667 13.8129 13.4587
280056...................................................... 14.0151 12.6475 15.6135 14.0018
280057...................................................... 15.7623 18.0454 20.0686 17.7576
280058...................................................... 17.8798 19.6752 21.4868 19.6876
280060...................................................... 28.6047 19.7527 20.7022 22.2434
280061...................................................... 17.9511 17.1629 18.6370 17.9240
280062...................................................... 13.6738 14.4896 15.6018 14.6170
280064...................................................... 15.5092 16.2977 16.8330 16.2046
280065...................................................... 18.5327 19.2932 20.7370 19.5513
280066...................................................... 11.6416 11.6621 11.7207 11.6766
280068...................................................... 10.1327 9.4943 10.5987 10.0463
280070...................................................... 13.7353 17.7400 22.6201 17.5276
280073...................................................... 17.0583 17.4244 17.7698 17.4266
280074...................................................... 15.2182 16.4310 17.3143 16.2521
280075...................................................... 13.7875 15.5327 13.2230 14.1041
280076...................................................... 13.9203 14.8469 16.7488 15.0947
280077...................................................... 19.0145 19.2068 20.0148 19.4096
280079...................................................... 9.9132 10.4540 16.6117 11.4307
280080...................................................... 14.3528 15.3308 16.9487 15.6285
280081...................................................... 20.9196 21.0771 20.9606 20.9873
280082...................................................... 13.1250 14.3399 14.6173 14.0723
280083...................................................... 17.5544 18.2992 21.5336 19.2134
280084...................................................... 11.6868 12.5836 13.6536 12.6157
280085...................................................... 21.5793 20.4302 20.4825 20.9817
280088...................................................... 22.1147 20.2961 * 21.2560
280089...................................................... 17.4696 18.1668 18.9567 18.1923
280090...................................................... 14.7191 14.1362 15.1274 14.6962
280091...................................................... 15.2184 15.8436 16.1866 15.7538
280092...................................................... 14.1998 14.1945 14.7912 14.4303
280094...................................................... 15.8843 17.6873 16.3474 16.6450
280097...................................................... 14.2990 14.1734 13.8223 14.0824
280098...................................................... 10.1686 13.0029 12.5875 12.0141
280101...................................................... 17.4168 13.5261 16.9973 15.7528
[[Page 40000]]
280102...................................................... 12.9367 14.0102 * 13.4735
280104...................................................... 13.3842 13.2819 16.2167 14.1456
280105...................................................... 18.7851 18.6575 21.0735 19.5325
280106...................................................... 15.5396 16.1247 16.0679 15.9189
280107...................................................... 13.4553 13.3311 14.4679 13.7065
280108...................................................... 17.2185 17.5625 17.1961 17.3277
280109...................................................... 11.0622 12.6803 12.4408 12.0678
280110...................................................... 12.2950 12.7546 14.2136 13.0914
280111...................................................... 23.0856 21.8773 19.6283 21.4131
280114...................................................... 13.5580 15.7160 17.3076 15.4628
280115...................................................... 16.4282 16.7041 18.1480 17.1049
280117...................................................... 16.8216 17.7276 18.8279 17.8057
280118...................................................... 16.9228 16.8687 18.6524 17.4822
280123...................................................... 20.7732 14.0637 11.8582 15.0281
280125...................................................... * 16.1332 16.3944 16.2644
290001...................................................... 22.4188 22.8226 22.7450 22.6608
290002...................................................... 20.9442 17.2554 16.5419 18.3712
290003...................................................... 25.0066 22.8840 24.2175 23.9864
290005...................................................... 17.8609 19.4888 21.9814 19.6686
290006...................................................... 19.8815 21.8070 22.4063 21.4371
290007...................................................... 29.6864 29.7706 30.9075 30.1389
290008...................................................... 20.2506 20.6190 24.1255 21.5150
290009...................................................... 22.7399 23.3620 23.9373 23.3345
290010...................................................... 14.4800 15.6423 16.4476 15.5219
290011...................................................... 16.4419 20.1564 21.1234 19.0261
290012...................................................... 21.5139 21.8275 25.0430 22.8581
290013...................................................... 17.0883 18.2713 15.7932 17.0224
290014...................................................... 18.3755 18.9743 18.7829 18.7144
290015...................................................... 17.8303 22.3487 19.4504 19.7229
290016...................................................... 12.7869 14.3542 23.8656 16.2244
290019...................................................... 20.9336 21.2509 22.2045 21.4895
290020...................................................... 26.1502 20.8733 21.2380 22.7207
290021...................................................... 21.1250 21.5806 22.9488 21.8726
290022...................................................... 24.0856 24.5468 25.5011 24.7398
290027...................................................... 16.4289 16.7786 13.3769 15.4098
290032...................................................... 22.7882 22.8447 23.9504 23.1730
290036...................................................... 18.6112 * 12.9074 15.9259
290038...................................................... 23.1402 20.6753 27.7030 22.6435
290039...................................................... 25.8004 25.3864 25.5024 25.5429
290041...................................................... * * 25.9905 25.9905
290042...................................................... * * 18.7527 18.7527
290043...................................................... * * 27.9053 27.9053
300001...................................................... 21.4192 22.0909 23.8567 22.4761
300003...................................................... 23.3777 22.9111 24.1297 23.4634
300005...................................................... 19.9876 20.7545 22.2858 20.9804
300006...................................................... 18.9331 23.7793 18.9745 20.5179
300007...................................................... 19.3447 20.2372 20.6325 20.0620
300008...................................................... 16.4649 20.7702 19.6149 18.9666
300009...................................................... 20.0057 18.0602 20.0938 19.3221
300010...................................................... 19.3833 19.3940 20.2130 19.6671
300011...................................................... 21.2429 22.4325 23.0279 22.1850
300012...................................................... 23.8859 24.5673 24.5619 24.3251
300013...................................................... 18.9664 19.1247 20.1669 19.4250
300014...................................................... 19.7969 20.3292 20.1774 20.0987
300015...................................................... 19.9308 20.4916 19.6627 20.0406
300016...................................................... 18.5037 21.8659 17.8148 19.4173
300017...................................................... 22.3408 21.6563 22.7191 22.2414
300018...................................................... 20.8947 21.2381 21.6385 21.2565
300019...................................................... 20.6090 20.9753 19.6728 20.4155
300020...................................................... 21.9725 21.9165 22.6627 22.2032
300021...................................................... 17.3477 18.6211 19.3101 18.4253
300022...................................................... 17.1864 18.3507 19.1875 18.2148
300023...................................................... 20.3909 22.1210 22.7649 21.7833
[[Page 40001]]
300024...................................................... 17.9460 19.9116 21.5842 19.6334
300028...................................................... 18.0515 17.4075 20.0778 18.5816
300029...................................................... 20.8961 22.5748 22.6013 22.0065
300033...................................................... 19.8506 17.1869 17.1632 17.9333
300034...................................................... 23.5215 25.5182 24.4975 24.5048
310001...................................................... 27.5967 28.1329 27.4730 27.7287
310002...................................................... 27.8735 28.3434 27.9728 28.0592
310003...................................................... 27.4152 29.1096 27.5624 28.0099
310005...................................................... 23.0493 22.1146 22.9712 22.6992
310006...................................................... 21.5557 21.5957 22.0894 21.7417
310008...................................................... 24.9483 23.5084 24.7618 24.4065
310009...................................................... 23.1906 23.6371 21.7094 22.8601
310010...................................................... 21.1064 22.5682 23.1060 22.2131
310011...................................................... 23.4038 23.1977 24.2885 23.6223
310012...................................................... 26.3249 26.5242 26.6772 26.5118
310013...................................................... 22.1062 21.2251 22.5603 21.9726
310014...................................................... 28.6964 27.4614 23.1956 26.3647
310015...................................................... 26.7584 27.4331 27.9684 27.3934
310016...................................................... 26.0518 24.3838 24.5206 24.9705
310017...................................................... 26.0703 25.7902 24.5976 25.5018
310018...................................................... 24.5312 22.8428 22.4779 23.3087
310019...................................................... 23.0888 24.0542 24.9914 24.0619
310020...................................................... 19.2663 24.1848 24.4152 22.3484
310021...................................................... 22.6456 23.9369 25.4393 23.9309
310022...................................................... 20.7276 21.2706 20.8258 20.9386
310024...................................................... 22.7831 24.2353 24.9521 23.9428
310025...................................................... 22.8129 24.3513 24.1812 23.7695
310026...................................................... 23.8726 23.5491 22.1997 23.2228
310027...................................................... 21.7666 21.8846 22.5696 22.0722
310028...................................................... 23.5188 23.4577 23.9428 23.6444
310029...................................................... 23.3801 22.6629 23.6610 23.2308
310031...................................................... 25.1780 26.1567 26.6831 25.9979
310032...................................................... 23.3017 24.3528 24.7404 24.1425
310034...................................................... 21.6851 23.2729 24.1150 22.9962
310036...................................................... 19.8178 20.1905 21.7187 20.5557
310037...................................................... 27.4447 27.7823 28.1289 27.7758
310038...................................................... 25.3832 26.7209 28.4893 26.9013
310039...................................................... 22.0259 22.1754 22.7317 22.2988
310040...................................................... 23.9864 26.1492 26.3573 25.4478
310041...................................................... 23.7829 24.8960 23.5559 24.0709
310042...................................................... 24.3292 23.2472 24.7678 24.1098
310043...................................................... 22.0887 21.9022 21.6128 21.8925
310044...................................................... 20.4309 21.6677 23.1549 21.6891
310045...................................................... 28.1570 28.4854 28.9274 28.5212
310047...................................................... 24.5225 25.1101 26.1921 25.2615
310048...................................................... 23.3295 23.6118 25.2870 24.0821
310049...................................................... 24.7617 24.8299 27.0842 25.4915
310050...................................................... 22.5877 25.1752 24.7988 24.2032
310051...................................................... 25.2762 27.1265 27.5378 26.5967
310052...................................................... 22.5753 22.9326 23.3973 22.9809
310054...................................................... 24.7413 26.1726 27.7376 26.1388
310057...................................................... 20.4484 21.1686 22.2572 21.2802
310058...................................................... 26.2243 26.5308 26.3765 26.3747
310060...................................................... 19.1119 19.1992 20.0997 19.4729
310061...................................................... 20.8023 23.2646 33.9582 25.0082
310062...................................................... 19.2729 22.9073 * 21.3672
310063...................................................... 21.8540 21.9045 22.1080 21.9521
310064...................................................... 24.2115 24.8567 25.4822 24.8391
310067...................................................... 22.2740 25.0888 23.9278 23.7333
310069...................................................... 24.1662 23.7531 24.2329 24.0530
310070...................................................... 25.0448 26.0903 28.2220 26.3630
310072...................................................... 22.2231 21.7605 22.5611 22.1704
310073...................................................... 25.6299 28.5149 26.2937 26.7849
[[Page 40002]]
310074...................................................... 24.4638 23.8340 22.3588 23.6496
310075...................................................... 26.4606 23.3266 24.4788 24.7522
310076...................................................... 28.8981 30.0797 27.9918 29.0283
310077...................................................... 25.0569 25.2500 26.1251 25.4460
310078...................................................... 23.4788 23.8841 24.0587 23.7967
310081...................................................... 23.8898 22.0762 22.4086 22.8084
310083...................................................... 23.6761 23.8852 24.8204 24.1353
310084...................................................... 24.0915 26.6753 24.6049 25.1157
310086...................................................... 21.4350 22.1674 23.1719 22.2404
310087...................................................... 20.8875 20.7243 21.1215 20.9125
310088...................................................... 22.3419 22.3160 23.1722 22.6064
310090...................................................... 24.2426 23.8284 24.8986 24.3109
310091...................................................... 22.0103 22.7978 23.2969 22.6743
310092...................................................... 22.3446 20.5165 21.6964 21.5200
310093...................................................... 21.2302 22.4291 23.7251 22.4166
310096...................................................... 26.3041 25.1572 24.5759 25.3591
310105...................................................... 24.4851 25.5891 26.2537 25.4282
310108...................................................... 22.8801 22.4756 23.8308 23.0488
310110...................................................... 20.1400 21.8341 23.2146 21.7904
310111...................................................... 21.7218 1.1066 22.1151 21.6430
310112...................................................... 22.5213 23.6701 24.7914 23.6656
310113...................................................... 22.9536 23.6841 23.1961 23.2803
310115...................................................... 20.0667 21.7320 21.1645 20.9731
310116...................................................... 25.2429 22.9812 23.6366 23.9253
310118...................................................... 24.5443 26.4625 26.1315 25.6352
310119...................................................... 29.4809 33.6686 32.7858 31.9394
310120...................................................... 21.6852 23.9681 23.3200 22.9127
310121...................................................... 18.7365 * * 18.7365
320001...................................................... 17.8522 19.1150 20.6225 19.1818
320002...................................................... 22.4623 22.6175 23.0983 22.7062
320003...................................................... 15.3484 15.9504 16.4642 15.9014
320004...................................................... 17.2353 18.5824 19.6642 18.5890
320005...................................................... 19.8698 21.6103 21.0411 20.8577
320006...................................................... 18.6472 18.9019 20.3863 19.2674
320009...................................................... 17.6400 18.2883 19.3500 18.4218
320011...................................................... 16.5481 20.0601 18.5222 18.4330
320012...................................................... 15.9972 16.4355 17.1764 16.5374
320013...................................................... 23.8390 22.9573 24.5543 23.8179
320014...................................................... 15.9666 16.3598 16.8412 16.4003
320016...................................................... 18.9296 20.5398 18.8519 19.4293
320017...................................................... 18.1545 18.6388 19.4498 18.7392
320018...................................................... 18.1944 18.8479 19.2336 18.7690
320019...................................................... 19.2600 24.4707 26.9637 23.5577
320021...................................................... 17.1647 17.8705 19.0457 17.9920
320022...................................................... 15.8391 16.1777 18.0606 16.7167
320023...................................................... 16.4170 18.0548 17.8419 17.3761
320030...................................................... 16.5266 16.5495 18.6859 17.1956
320031...................................................... 13.9914 19.6768 25.1715 19.2605
320032...................................................... 18.7536 18.8097 20.6871 19.3668
320033...................................................... 20.3137 25.0777 21.0621 21.9427
320035...................................................... 25.7392 21.5186 15.0612 19.2882
320037...................................................... 17.0846 17.0305 17.8280 17.3203
320038...................................................... 16.2896 16.8117 22.2664 18.6619
320046...................................................... 19.0033 18.3190 18.9607 18.7526
320048...................................................... 19.1705 19.9642 16.8769 18.5918
320063...................................................... 19.8320 18.3237 17.9089 18.6049
320065...................................................... 16.1046 16.7933 18.6525 17.1721
320067...................................................... 57.4818 33.8654 15.3228 25.9798
320068...................................................... 18.1809 17.4785 18.5103 18.1180
320069...................................................... 11.3058 13.0094 14.4212 12.8497
320074...................................................... 18.6545 19.3406 20.2290 19.3600
320079...................................................... 17.0696 18.2828 19.8555 18.3645
330001...................................................... 25.2067 26.5533 27.3996 26.4208
[[Page 40003]]
330002...................................................... 26.3926 26.5370 26.9341 26.6121
330003...................................................... 18.0549 19.4102 18.9211 18.7797
330004...................................................... 19.9573 22.5298 20.9501 21.1368
330005...................................................... 24.2795 24.8338 22.1957 23.2739
330006...................................................... 25.9186 25.0576 25.8006 25.5856
330007...................................................... 18.7956 18.9024 * 18.8475
330008...................................................... 18.0684 19.0045 19.2341 18.7497
330009...................................................... 30.4220 30.6918 31.3435 30.8056
330010...................................................... 14.7382 17.4512 16.6508 16.1432
330011...................................................... 18.0419 18.2986 18.6748 18.3483
330012...................................................... 31.5135 32.7624 * 32.1317
330013...................................................... 19.9929 19.0856 19.6269 19.5703
330014...................................................... 27.5704 32.3370 36.8669 32.2778
330016...................................................... 17.4069 16.9717 16.8016 17.0572
330019...................................................... 32.4515 35.9822 33.5369 34.0043
330020...................................................... 14.5488 15.5527 15.1142 15.0641
330023...................................................... 24.2708 24.4006 25.6512 24.7835
330024...................................................... 33.6175 34.1682 37.3316 34.9189
330025...................................................... 16.0290 16.2033 16.8687 16.3599
330027...................................................... 32.4959 33.4738 35.5255 33.7629
330028...................................................... 27.0752 28.2089 29.5294 28.2349
330029...................................................... 16.5552 18.1567 17.0016 17.2536
330030...................................................... 15.0551 17.4977 19.1085 16.8779
330033...................................................... 16.7497 18.5353 17.4444 17.6068
330034...................................................... 30.7840 31.3997 27.7738 30.5701
330036...................................................... 24.3239 23.9874 25.2820 24.5370
330037...................................................... 16.0026 16.1140 16.4866 16.2081
330038...................................................... 16.0153 16.2549 17.3429 16.5336
330039...................................................... 12.4666 * * 12.4666
330041...................................................... 30.4192 24.5215 31.4871 28.4761
330043...................................................... 27.6286 28.7467 27.4661 27.9537
330044...................................................... 18.6969 20.0238 19.5219 19.4106
330045...................................................... 27.1759 28.0758 27.9919 27.7401
330046...................................................... 31.9802 32.4189 35.2703 33.1562
330047...................................................... 17.6895 18.1815 18.5536 18.1416
330048...................................................... 17.6239 17.8787 19.1093 18.1878
330049...................................................... 19.3136 19.4993 20.5731 19.7930
330053...................................................... 15.6659 17.4430 17.8082 16.9823
330055...................................................... 30.7330 36.1109 32.8910 33.1680
330056...................................................... 30.2206 30.4525 30.0945 30.2540
330057...................................................... 18.6891 18.7478 19.3643 18.9410
330058...................................................... 16.9805 17.0014 17.7672 17.2379
330059...................................................... 32.2285 34.1705 34.2426 33.4744
330061...................................................... 25.0674 25.7331 25.4082 25.4024
330062...................................................... 15.2819 17.6067 18.1318 16.9856
330064...................................................... 32.8724 33.1269 33.6447 33.2084
330065...................................................... 18.3686 19.8940 19.9305 19.3468
330066...................................................... 19.9455 19.5611 18.8707 19.4674
330067...................................................... 21.2872 20.9443 22.1065 21.4528
330072...................................................... 29.3096 30.8019 30.4171 30.1659
330073...................................................... 15.8849 16.2898 16.4518 16.2013
330074...................................................... 18.1636 18.0005 17.7308 17.9678
330075...................................................... 17.4266 17.2298 17.6385 17.4324
330078...................................................... 17.4863 16.7949 18.7884 17.6577
330079...................................................... 16.7608 17.4555 18.7622 17.6535
330080...................................................... 26.8766 29.2686 31.4424 29.0970
330084...................................................... 23.0327 18.0435 19.3216 19.8703
330085...................................................... 18.7835 20.2926 20.6203 19.8951
330086...................................................... 30.6954 31.2980 23.6496 28.6407
330088...................................................... 25.6160 25.6626 25.7940 25.6905
330090...................................................... 18.6833 19.3954 19.2112 19.0937
330091...................................................... 18.5334 19.0953 19.7776 19.1249
330092...................................................... 12.6540 14.0671 13.3723 13.3059
[[Page 40004]]
330094...................................................... 17.7196 17.5585 18.1582 17.8207
330095...................................................... 18.5502 20.1073 21.1096 19.8197
330096...................................................... 16.5963 17.9641 18.5149 17.6975
330097...................................................... 16.9626 16.2169 16.4433 16.5145
330100...................................................... 28.1060 27.0661 29.0916 28.0415
330101...................................................... 31.3075 32.4105 31.5914 31.7153
330102...................................................... 17.5230 17.5755 19.0058 18.0012
330103...................................................... 16.5212 15.7197 16.8110 16.3435
330104...................................................... 28.7669 31.6471 31.2074 30.5068
330106...................................................... 35.8740 40.2686 35.3775 37.0516
330107...................................................... 28.0780 28.5580 27.7797 28.1411
330108...................................................... 17.0846 17.3605 18.0786 17.5050
330111...................................................... 15.2047 19.5314 15.9321 16.7001
330114...................................................... 18.2390 17.3522 17.0581 17.5626
330115...................................................... 16.5581 17.4430 17.4684 17.1455
330116...................................................... 24.2266 24.4622 14.9610 20.6732
330118...................................................... 20.7550 20.6936 * 20.7240
330119...................................................... 34.7478 34.8385 33.1179 34.2290
330121...................................................... 15.8468 16.1052 16.3385 16.0964
330122...................................................... 21.2021 20.8204 20.2417 20.7389
330125...................................................... 19.7456 19.8494 19.7638 19.7865
330126...................................................... 22.6990 23.7938 23.8957 23.4789
330127...................................................... 29.3317 31.9046 30.7356 30.6271
330128...................................................... 27.8693 29.0222 30.8242 29.1534
330132...................................................... 14.7006 15.7633 14.3673 14.9673
330133...................................................... 32.3812 37.2494 35.3576 34.8196
330135...................................................... 18.3346 18.7120 22.2670 19.6717
330136...................................................... 17.6041 18.2422 20.1043 18.6252
330140...................................................... 19.5016 19.1438 19.3615 19.3334
330141...................................................... 25.1371 26.4956 26.7096 26.0966
330144...................................................... 15.5068 14.0566 16.2517 15.2343
330148...................................................... 15.0400 16.8151 16.2782 16.0197
330151...................................................... 13.9700 16.0714 15.7594 15.2313
330152...................................................... 29.4818 30.5409 30.8314 30.2117
330153...................................................... 17.4996 18.9689 18.1776 18.1944
330157...................................................... 20.8239 22.0792 22.3804 21.7687
330158...................................................... 26.0476 25.7569 27.1228 26.3184
330159...................................................... 18.0211 19.1536 19.4998 18.8640
330160...................................................... 30.5678 32.7840 29.5885 30.9340
330162...................................................... 27.7162 27.1166 27.6010 27.4784
330163...................................................... 20.4555 18.7816 20.7456 19.9795
330164...................................................... 19.4831 19.8647 20.9003 20.0827
330166...................................................... 14.1815 15.0954 15.4420 14.8722
330167...................................................... 31.1834 29.3634 30.2346 30.2561
330169...................................................... 33.4462 37.2655 35.4794 35.3665
330171...................................................... 25.4314 25.5307 24.8035 25.2597
330175...................................................... 16.6851 17.3290 18.3116 17.4443
330177...................................................... 14.5378 17.2907 16.3704 16.0830
330179...................................................... 12.6857 13.4999 13.8953 13.3684
330180...................................................... 15.5304 16.8787 17.9877 16.7426
330181...................................................... 32.4718 32.5192 33.0908 32.6900
330182...................................................... 30.9260 32.9371 33.6531 32.5479
330183...................................................... 19.9964 19.9207 20.6164 20.1809
330184...................................................... 27.4859 30.0400 31.3706 29.6316
330185...................................................... 26.9496 25.6112 26.8612 26.4537
330188...................................................... 18.7208 20.9587 18.8000 19.4696
330189...................................................... 17.6585 15.1253 18.4498 16.9610
330191...................................................... 18.8586 18.6206 19.0348 18.8384
330193...................................................... 29.8042 36.5481 30.2260 31.8162
330194...................................................... 35.5748 34.6785 35.2036 35.1664
330195...................................................... 31.3915 33.3254 34.8966 33.0747
330196...................................................... 28.4465 30.8165 30.5799 29.9142
330197...................................................... 16.9990 17.6646 18.3527 17.6922
[[Page 40005]]
330198...................................................... 23.8113 24.6038 24.8590 24.4203
330199...................................................... 27.6605 28.7609 30.5409 28.9499
330201...................................................... 30.3293 32.1149 28.7861 30.4144
330202...................................................... 30.7869 31.4435 31.2575 31.1487
330203...................................................... 19.2353 20.7575 25.0345 21.5038
330204...................................................... 29.3662 29.4418 32.2005 30.2707
330205...................................................... 19.4642 20.5793 22.3490 20.7832
330208...................................................... 25.8201 26.1822 26.6682 26.2220
330209...................................................... 24.8834 23.9924 25.1281 24.6749
330211...................................................... 19.0968 19.5064 19.5405 19.3836
330212...................................................... 21.1777 21.7705 24.7681 22.5597
330213...................................................... 18.5066 18.7722 19.6796 18.9552
330214...................................................... 32.1966 36.4447 32.4292 33.4440
330215...................................................... 17.5818 19.6926 17.9863 18.3902
330218...................................................... 21.7072 21.4796 21.1890 21.4557
330219...................................................... 22.1476 23.9908 23.4310 23.1411
330221...................................................... 32.2081 27.8485 33.3796 31.2840
330222...................................................... 17.8140 18.3666 18.5571 18.2482
330223...................................................... 17.2754 17.6199 17.8306 17.5845
330224...................................................... 21.9728 19.6410 20.4309 20.7047
330225...................................................... 25.8043 25.5823 27.0379 26.0910
330226...................................................... 17.6708 16.6711 23.1859 18.8241
330229...................................................... 16.2509 16.8026 17.5326 16.8453
330230...................................................... 28.8625 29.7626 29.6283 29.3810
330231...................................................... 29.0917 30.0923 32.7200 30.4677
330232...................................................... 19.5042 17.9083 19.1787 18.8569
330233...................................................... 33.3008 30.9241 44.1265 35.0751
330234...................................................... 33.3286 35.1777 35.0720 34.4830
330235...................................................... 19.4532 21.0842 19.5880 20.0417
330236...................................................... 30.7017 29.5913 31.3463 30.5397
330238...................................................... 14.7951 15.6245 17.3976 15.9047
330239...................................................... 17.2808 17.4462 18.5079 17.7328
330240...................................................... 30.4765 29.7082 30.7321 30.2841
330241...................................................... 22.6046 24.6076 23.8638 23.6409
330242...................................................... 24.7401 28.2612 27.6384 26.8305
330245...................................................... 17.2803 17.6767 18.5161 17.8488
330246...................................................... 26.6587 28.1090 28.1205 27.6612
330247...................................................... 27.6203 28.5310 27.3937 27.8277
330249...................................................... 16.4818 16.2687 17.1320 16.6304
330250...................................................... 19.5553 19.5823 19.9619 19.7058
330252...................................................... 17.0379 * * 17.0379
330254...................................................... 16.7252 18.4057 15.9123 17.0146
330258...................................................... 30.4656 29.7426 31.8910 30.6921
330259...................................................... 25.2526 26.2661 25.9994 25.8364
330261...................................................... 26.1654 25.7244 27.9766 26.6137
330263...................................................... 19.6388 20.4149 18.7378 19.6517
330264...................................................... 23.1359 22.8672 22.8099 22.9301
330265...................................................... 15.6249 18.0193 17.6301 17.0414
330267...................................................... 23.5561 24.5183 24.5939 24.2287
330268...................................................... 14.6249 13.0595 15.9060 14.5364
330270...................................................... 28.2392 34.4254 36.0824 32.6382
330273...................................................... 25.8910 23.1511 26.0565 24.9430
330275...................................................... 17.4223 19.0548 18.7268 18.3387
330276...................................................... 17.7452 18.2870 19.0228 18.3342
330277...................................................... 17.1570 18.3169 19.1761 18.2131
330279...................................................... 19.9079 19.5983 20.7107 20.0436
330285...................................................... 22.4717 23.5264 24.0491 23.3509
330286...................................................... 25.0948 26.7633 27.7762 26.5916
330290...................................................... 32.5792 33.5056 30.4706 32.2470
330293...................................................... 15.3782 16.2158 16.9238 16.1248
330304...................................................... 29.3687 26.7683 27.3562 27.8227
330306...................................................... 27.6214 27.3798 29.5937 28.1525
330307...................................................... 20.7362 21.0673 21.7257 21.1725
[[Page 40006]]
330308...................................................... 36.8361 * * 36.8361
330314...................................................... 24.7399 24.5444 25.9937 25.0514
330316...................................................... 28.7872 27.6102 27.9543 28.1177
330327...................................................... 16.9724 16.4611 20.3874 17.9258
330331...................................................... 31.0405 31.6216 33.1276 32.0298
330332...................................................... 27.1554 27.6914 25.3689 26.7855
330333...................................................... * 29.1931 * 29.1931
330336...................................................... 30.1708 29.7689 29.8294 29.9290
330338...................................................... 23.0077 22.4581 21.2670 22.2755
330339...................................................... 19.6730 20.0111 20.1028 19.9220
330340...................................................... 26.9201 28.8419 28.4129 28.0687
330350...................................................... 30.3754 30.8889 30.9763 30.7427
330353...................................................... 33.5519 32.1984 34.2431 33.3163
330357...................................................... 34.7492 36.5928 34.1846 35.2059
330359...................................................... 29.2920 * * 29.2920
330372...................................................... 22.5027 28.8482 33.3771 27.5982
330381...................................................... 29.2438 31.0091 31.8602 30.6612
330385...................................................... 28.8373 35.6722 33.2246 32.4207
330386...................................................... 24.6713 17.6383 20.4231 20.5236
330389...................................................... 32.4234 30.2505 37.3749 32.9392
330390...................................................... 29.7936 31.1577 30.8744 30.5843
330393...................................................... 27.9901 26.4958 27.8352 27.4232
330394...................................................... 18.7724 19.2392 18.9343 18.9816
330395...................................................... 37.6805 32.8749 32.7494 34.3792
330396...................................................... 30.7228 34.8648 30.7961 32.1685
330397...................................................... 31.0043 33.9061 32.6068 32.3768
330398...................................................... 30.3217 28.7707 29.2872 29.6846
330399...................................................... 35.5212 32.9100 33.3012 33.9214
330400...................................................... * * 16.2707 16.2707
340001...................................................... 19.0159 18.1814 19.7093 18.9605
340002...................................................... 18.7790 20.8858 20.5253 20.0921
340003...................................................... 21.9674 20.2540 19.5145 20.4958
340004...................................................... 17.8923 19.0695 20.9863 19.3245
340005...................................................... 14.0941 15.8205 16.7176 15.5039
340006...................................................... 17.8145 16.9818 16.5709 17.0955
340007...................................................... 17.1708 17.2356 18.3399 17.5929
340008...................................................... 18.3769 21.2889 20.4157 20.0279
340009...................................................... 20.5011 20.5023 20.9178 20.6132
340010...................................................... 17.6500 18.3380 19.4302 18.4900
340011...................................................... 14.9215 13.6554 14.4798 14.3110
340012...................................................... 16.6574 18.8701 17.5112 17.6905
340013...................................................... 17.4302 20.1747 19.4613 19.0754
340014...................................................... 19.9203 20.5748 27.7888 22.1408
340015...................................................... 19.0056 20.1562 19.4676 19.5517
340016...................................................... 16.3977 17.5404 18.8958 17.5664
340017...................................................... 19.2203 19.4192 20.2775 19.6581
340018...................................................... 15.1579 14.0930 18.1751 15.6569
340019...................................................... 13.5919 14.8980 15.2887 14.5682
340020...................................................... 16.7515 18.6334 18.0897 17.8512
340021...................................................... 19.6658 19.8020 20.5813 20.0277
340022...................................................... 16.7211 17.8178 18.7714 17.7886
340023...................................................... 17.2054 18.5414 19.3146 18.3540
340024...................................................... 16.6389 17.3824 17.9130 17.3104
340025...................................................... 16.8198 17.2648 18.4628 17.5179
340027...................................................... 17.2971 18.0816 19.4548 18.2602
340028...................................................... 17.7196 18.4787 19.9403 18.7490
340030...................................................... 20.0530 21.1420 22.4709 21.2046
340031...................................................... 12.3895 14.6951 14.6370 13.8761
340032...................................................... 20.4735 20.0049 20.7444 20.4083
340035...................................................... 18.0988 20.2312 18.9930 19.1067
340036...................................................... 16.9674 18.2190 17.7619 17.6323
340037...................................................... 15.5347 16.6576 17.5829 16.5842
340038...................................................... 17.0154 17.3762 18.1493 17.5050
[[Page 40007]]
340039...................................................... 20.1470 20.5876 21.3711 20.7125
340040...................................................... 20.1214 20.4282 20.7237 20.4264
340041...................................................... 17.7626 15.1419 15.5873 16.0395
340042...................................................... 16.6300 16.9298 17.0034 16.8680
340044...................................................... 16.3657 18.8687 18.0863 17.7757
340045...................................................... 12.4152 13.0538 13.6182 12.9769
340047...................................................... 19.6050 20.0602 20.0744 19.9132
340049...................................................... 16.4988 19.2050 19.5127 18.2917
340050...................................................... 18.5570 20.0090 19.6726 19.4142
340051...................................................... 18.5953 16.5617 19.3627 18.0980
340052...................................................... 21.3746 22.8173 23.2134 22.4161
340053...................................................... 19.4881 20.9495 19.9915 20.1403
340054...................................................... 14.4722 15.5993 15.5090 15.2167
340055...................................................... 18.1786 19.6056 19.4035 19.0752
340060...................................................... 17.9167 18.7137 19.3410 18.6670
340061...................................................... 20.8474 21.5385 22.1175 21.4855
340063...................................................... 16.9232 17.0249 16.7377 16.9005
340064...................................................... 17.2584 20.7125 18.5069 18.8299
340065...................................................... 18.3212 17.5414 17.3530 17.7394
340067...................................................... 18.6132 19.3785 19.7187 19.2365
340068...................................................... 16.7015 16.6305 17.8065 17.0483
340069...................................................... 19.9948 21.0840 21.6728 20.9166
340070...................................................... 18.6270 19.7796 20.6829 19.7122
340071...................................................... 16.3701 17.1424 18.0767 17.2043
340072...................................................... 15.6014 16.7400 17.7129 16.7307
340073...................................................... 20.6905 21.9761 23.5832 22.0016
340075...................................................... 18.2060 18.7090 20.0081 18.9541
340080...................................................... 16.8453 22.2533 18.2061 19.0642
340084...................................................... 21.7813 17.1532 19.0103 19.0182
340085...................................................... 16.2355 17.3462 18.3179 17.3020
340087...................................................... 16.6987 17.3884 18.2255 17.4652
340088...................................................... 19.8314 21.0226 22.2322 21.0156
340089...................................................... 13.8633 13.8535 15.4760 14.4308
340090...................................................... 17.8457 17.0584 18.5287 17.8139
340091...................................................... 19.3955 20.5923 20.3861 20.1343
340093...................................................... 15.1615 16.3276 16.8903 16.0870
340094...................................................... 15.9568 19.0406 * 17.4328
340096...................................................... 17.9764 17.8189 19.4696 18.4348
340097...................................................... 21.3700 18.8412 18.2399 19.4192
340098...................................................... 20.1671 21.4135 21.9578 21.2065
340099...................................................... 15.0888 16.8305 15.3752 15.7269
340101...................................................... 15.3610 13.9994 15.6509 14.9555
340104...................................................... 15.8729 13.0462 11.5169 13.4465
340105...................................................... 18.9007 20.2954 * 19.5963
340106...................................................... 18.0769 17.7220 18.1211 17.9704
340107...................................................... 16.9503 18.0205 19.3197 18.0904
340109...................................................... 17.9576 18.7746 19.0532 18.6067
340111...................................................... 14.9247 16.3344 16.5976 15.9665
340112...................................................... 14.5966 14.7562 15.5142 14.9625
340113...................................................... 20.8821 21.2906 21.9883 21.3854
340114...................................................... 20.8195 21.2166 20.7261 20.9197
340115...................................................... 18.6700 19.7578 21.7586 20.0594
340116...................................................... 19.4786 20.4255 20.6800 20.2116
340119...................................................... 16.8537 18.8507 19.5827 18.4595
340120...................................................... 14.3822 15.0410 15.8240 15.1047
340121...................................................... 15.9686 16.3295 17.8771 16.7251
340123...................................................... 16.2227 16.9114 18.9078 17.3848
340124...................................................... 14.0462 15.5779 17.4185 15.7171
340125...................................................... 19.6252 19.7164 20.2748 19.8633
340126...................................................... 17.7214 18.8100 19.3734 18.6747
340127...................................................... 17.3849 19.3925 19.3842 18.7105
340129...................................................... 19.7332 20.4605 20.6521 20.2893
340130...................................................... 19.4430 19.7422 19.8707 19.6940
[[Page 40008]]
340131...................................................... 18.9361 19.7908 21.3849 20.0481
340132...................................................... 16.9369 17.3448 17.5711 17.3015
340133...................................................... 14.3501 16.4766 17.2138 16.0568
340137...................................................... * 21.0249 31.7702 23.8273
340138...................................................... 19.2807 20.7618 * 20.0092
340141...................................................... 22.2234 21.3754 21.4986 21.6898
340142...................................................... 16.0912 17.1525 18.0766 17.1107
340143...................................................... 20.9509 21.3604 24.4098 22.2423
340144...................................................... 19.1919 20.9113 22.9183 20.9333
340145...................................................... 19.1964 20.1081 19.9233 19.7573
340146...................................................... 13.0119 15.9203 17.3051 15.3284
340147...................................................... 19.1087 19.6827 20.5520 19.8121
340148...................................................... 18.4227 18.5875 18.9912 18.6555
340151...................................................... 16.5671 16.7275 18.4733 17.2579
340153...................................................... 20.6588 20.6420 20.7533 20.6847
340155...................................................... 20.4236 20.5792 23.1021 21.3418
340158...................................................... 17.2565 18.1439 19.0843 18.2232
340159...................................................... 16.8048 17.3893 19.0338 17.7595
340160...................................................... 15.5298 16.1778 16.7170 16.1477
340162...................................................... 16.6362 14.3472 * 16.3541
340164...................................................... 19.6820 21.2523 21.5769 20.8240
340166...................................................... 19.1743 20.0434 20.8270 20.0663
340168...................................................... 14.7508 15.2919 15.6071 15.2494
340171...................................................... 20.0495 21.5973 22.4779 21.4041
340173...................................................... 20.2132 19.3353 21.0898 20.2512
350001...................................................... 11.7345 14.9080 16.6551 14.4005
350002...................................................... 17.2834 17.5259 18.3459 17.7122
350003...................................................... 17.4276 18.2470 19.2840 18.3041
350004...................................................... 17.9049 20.6518 23.7016 20.6528
350005...................................................... 16.0259 18.3792 19.9156 18.1833
350006...................................................... 16.6241 18.4107 19.0343 17.9691
350007...................................................... 13.2771 13.3292 13.8824 13.4842
350008...................................................... 21.6983 20.4777 22.3783 21.4889
350009...................................................... 18.2818 19.1611 18.3688 18.6099
350010...................................................... 15.2762 16.2808 16.6272 16.0505
350011...................................................... 18.4931 18.2008 19.1944 18.6474
350012...................................................... 12.7287 15.7033 18.2524 15.6975
350013...................................................... 16.6784 16.4579 17.2596 16.7923
350014...................................................... 15.7906 16.8403 18.0999 16.8354
350015...................................................... 15.8651 16.3397 17.1071 16.3998
350016...................................................... 11.6255 11.6524 * 11.6395
350017...................................................... 17.7835 17.6278 17.5124 17.6446
350018...................................................... 13.6366 14.4928 16.4939 14.8276
350019...................................................... 19.4037 19.3063 20.1608 19.6008
350021...................................................... 12.6885 16.2898 17.7123 15.5294
350023...................................................... 12.7952 17.9048 17.4983 16.4355
350024...................................................... 14.3740 14.7529 15.4788 14.8361
350025...................................................... 16.2400 17.1199 15.0469 16.0889
350027...................................................... 17.1177 15.0835 15.5178 15.9200
350029...................................................... 12.7950 13.5219 14.6173 13.6002
350030...................................................... 17.3497 17.7209 18.1131 17.7195
350033...................................................... 14.8953 14.9012 16.0870 15.2715
350034...................................................... 18.3180 18.7245 19.6445 18.8742
350035...................................................... 10.1561 10.4570 11.7675 10.7676
350038...................................................... 18.7357 17.6666 19.6854 18.6648
350039...................................................... 17.3128 17.0361 16.6278 17.0024
350041...................................................... 14.6772 14.6680 19.1341 15.9095
350042...................................................... 16.7544 16.7402 19.3309 17.4345
350043...................................................... 17.1573 16.8876 16.7433 16.9224
350044...................................................... 10.5296 10.2154 11.0601 10.5801
350047...................................................... 17.9270 14.4628 18.0094 16.8202
350049...................................................... 14.5330 14.8019 18.1993 15.6280
350050...................................................... 10.5733 11.4921 12.2183 11.3924
[[Page 40009]]
350051...................................................... 17.5323 17.7279 17.0653 17.4458
350053...................................................... 13.9379 14.6398 15.9160 14.8075
350055...................................................... 12.3722 14.5691 15.7916 14.3152
350056...................................................... 14.7382 14.8293 15.0995 14.8885
350058...................................................... 14.3484 15.9378 16.7034 15.7009
350060...................................................... 9.5962 10.3666 10.3076 10.0926
350061...................................................... 14.5894 15.7269 18.8790 16.4237
360001...................................................... 17.3933 17.0791 19.6655 18.0423
360002...................................................... 17.3955 18.0139 18.2613 17.9462
360003...................................................... 22.0351 22.7471 22.7521 22.5117
360006...................................................... 22.0906 21.8048 22.4436 22.1137
360007...................................................... 17.0955 18.0941 14.8213 16.6387
360008...................................................... 17.8185 18.5439 18.7961 18.3915
360009...................................................... 17.5328 18.9322 18.9935 18.4667
360010...................................................... 18.0886 19.2288 19.1852 18.8325
360011...................................................... 18.9491 19.3835 21.3659 19.9105
360012...................................................... 19.2221 19.9881 20.0525 19.7649
360013...................................................... 20.8112 20.6021 21.3690 20.9190
360014...................................................... 19.8844 20.2390 20.7419 20.2907
360016...................................................... 18.7709 17.8065 21.2505 19.1632
360017...................................................... 22.4972 21.7543 22.2740 22.1696
360018...................................................... 21.3436 23.5219 24.6686 23.0168
360019...................................................... 20.1726 18.7147 20.6480 19.8139
360020...................................................... 22.9512 21.7806 22.1751 22.3268
360024...................................................... 18.5412 19.8508 20.1352 19.5008
360025...................................................... 19.2918 20.3638 20.2531 19.9763
360026...................................................... 17.0378 18.2222 17.9523 17.7450
360027...................................................... 20.3568 21.0406 21.7650 21.0544
360028...................................................... 17.2681 17.0177 18.7174 17.5937
360029...................................................... 18.2193 18.7622 19.2928 18.7626
360030...................................................... 15.3535 17.5748 17.6058 16.8173
360031...................................................... 19.8987 19.3858 21.0687 20.1028
360032...................................................... 17.9274 18.6559 19.8020 18.7667
360034...................................................... 15.5649 14.9534 17.9594 16.1258
360035...................................................... 20.3358 20.5557 21.0674 20.6574
360036...................................................... 19.1835 20.2107 20.9916 20.1250
360037...................................................... 22.5240 23.5094 23.1674 23.0445
360038...................................................... 19.8921 21.2467 19.9415 20.3576
360039...................................................... 17.4033 18.7791 19.0013 18.5872
360040...................................................... 18.1238 18.1618 18.7425 18.3503
360041...................................................... 18.4244 19.5744 19.7968 19.2697
360042...................................................... 16.1187 17.4306 17.1952 16.9328
360044...................................................... 16.7925 17.0612 17.6882 17.1993
360045...................................................... 21.1814 22.1471 22.4018 21.8209
360046...................................................... 19.3198 20.4755 20.4607 20.0909
360047...................................................... 15.3399 17.1871 15.2922 15.8884
360048...................................................... 21.1719 22.5857 22.4890 22.0646
360049...................................................... 18.8084 20.4564 20.8393 20.0008
360050...................................................... 12.8888 12.9873 15.0568 13.6080
360051...................................................... 20.9461 20.8338 20.8757 20.8844
360052...................................................... 20.0182 19.6233 18.7931 19.5088
360054...................................................... 16.1875 17.2574 17.4911 16.9860
360055...................................................... 23.2671 21.5585 21.4112 22.0925
360056...................................................... 18.7606 19.0474 20.6968 19.5385
360057...................................................... 13.8094 15.0146 15.8569 14.8518
360058...................................................... 17.9178 18.6992 19.3306 18.6392
360059...................................................... 21.9689 20.5618 19.9304 20.8679
360062...................................................... 20.3111 20.7588 21.9195 20.9548
360063...................................................... 22.7866 18.4512 17.5108 19.4998
360064...................................................... 20.6416 20.4846 20.0615 20.4087
360065...................................................... 19.4531 20.0532 19.6199 19.7128
360066...................................................... 20.0285 21.6015 22.8175 21.4937
360067...................................................... 14.5687 15.3157 14.2745 14.7189
[[Page 40010]]
360068...................................................... 21.2199 21.2789 22.6227 21.7164
360069...................................................... 17.8329 16.6982 14.6597 16.2292
360070...................................................... 17.5300 17.3758 18.8406 17.9171
360071...................................................... 23.8013 17.9756 19.0302 20.2494
360072...................................................... 17.9697 18.1467 19.0166 18.3995
360074...................................................... 18.2614 20.8275 18.5889 19.1849
360075...................................................... 18.4733 22.4523 26.0663 21.4074
360076...................................................... 19.5864 20.0700 20.3317 20.0010
360077...................................................... 20.8202 21.1053 21.5517 21.1550
360078...................................................... 20.7940 21.4392 22.6490 21.6280
360079...................................................... 22.0033 22.1096 21.6644 21.9274
360080...................................................... 16.6414 17.3892 17.6369 17.2080
360081...................................................... 19.6354 21.7342 20.4614 20.6451
360082...................................................... 22.8585 22.9460 20.7610 22.1460
360083...................................................... 18.4635 * * 18.4635
360084...................................................... 20.0914 20.4894 22.0492 20.8664
360085...................................................... 21.6670 21.9051 21.5151 21.7121
360086...................................................... 17.0389 19.5378 19.3701 18.5836
360087...................................................... 20.0395 20.1684 20.7969 20.3249
360088...................................................... 22.3121 24.0097 24.0822 23.4637
360089...................................................... 20.5610 18.3881 18.1941 19.0415
360090...................................................... 20.3955 21.0376 20.8971 20.7887
360091...................................................... 21.0335 21.3126 21.8447 21.4132
360092...................................................... 15.9095 20.4534 21.5073 18.9727
360093...................................................... 18.5744 19.3292 19.0261 18.9905
360094...................................................... 18.3105 18.8780 20.1227 19.0848
360095...................................................... 18.7079 20.4149 19.8521 19.6643
360096...................................................... 17.1617 18.2215 19.6726 18.3160
360098...................................................... 18.3361 19.5314 19.8178 19.2371
360099...................................................... 18.5523 18.5855 19.6241 18.9389
360100...................................................... 17.6554 17.8989 18.0442 17.8625
360101...................................................... 22.3121 21.3914 20.2635 21.3487
360102...................................................... 19.7700 19.4345 18.5367 19.2837
360103...................................................... 22.6228 * * 22.6228
360106...................................................... 16.1843 18.9752 19.1778 18.1964
360107...................................................... 18.6195 19.7599 22.1359 20.1794
360108...................................................... 16.5076 17.5832 20.0681 18.0497
360109...................................................... 19.5162 20.1032 19.9237 19.8530
360112...................................................... 22.5676 22.5589 24.6335 23.2167
360113...................................................... 22.4584 24.2654 20.8154 22.4061
360114...................................................... 16.3288 17.8761 18.7509 17.6758
360115...................................................... 18.1859 18.8059 20.7652 19.2888
360116...................................................... 18.0835 18.8882 18.8319 18.6000
360118...................................................... 18.6098 19.3732 19.9141 19.3196
360121...................................................... 21.0979 22.1093 22.2175 21.8088
360123...................................................... 19.1313 20.3236 20.9792 20.1480
360125...................................................... 18.1756 19.0774 20.5508 19.2432
360126...................................................... 20.4558 19.0036 24.5387 21.1181
360127...................................................... 16.9228 17.5882 16.5559 16.9955
360128...................................................... 15.5823 16.1243 17.0515 16.2361
360129...................................................... 15.5241 15.5002 16.6114 15.8783
360130...................................................... 15.3356 17.2009 18.4539 16.9275
360131...................................................... 18.2897 19.2241 18.4688 18.6543
360132...................................................... 18.2733 19.9171 21.3493 19.8413
360133...................................................... 19.0349 19.4316 20.2857 19.5509
360134...................................................... 20.2383 20.6876 20.9564 20.6143
360136...................................................... 17.8473 17.7827 18.2194 17.9464
360137...................................................... 20.2581 20.1756 22.3648 20.9095
360140...................................................... 19.1263 20.2791 21.2881 20.2299
360141...................................................... 22.8496 23.0016 23.5343 23.1176
360142...................................................... 17.3154 17.0059 18.3188 17.5468
360143...................................................... 20.4378 20.1989 21.0336 20.5552
360144...................................................... 21.9159 23.2191 20.9033 21.9858
[[Page 40011]]
360145...................................................... 19.3907 19.6413 20.0513 19.6956
360147...................................................... 16.5898 16.6616 17.6779 16.9779
360148...................................................... 18.8914 19.2816 19.1393 19.1100
360149...................................................... 18.7891 19.9808 * 19.3785
360150...................................................... 20.6253 21.1327 22.3620 21.3641
360151...................................................... 17.4863 16.6019 19.2788 17.7101
360152...................................................... 21.9978 20.8328 21.6005 21.4611
360153...................................................... 14.8948 15.4132 16.7399 15.6460
360154...................................................... 13.7761 14.3270 14.3593 14.1608
360155...................................................... 20.8977 22.5347 22.2112 21.8776
360156...................................................... 17.9155 17.8787 18.9095 18.2225
360159...................................................... 20.7119 20.2841 21.5695 20.8609
360161...................................................... 19.4122 19.1983 20.6160 19.7228
360162...................................................... 18.6084 * * 18.6084
360163...................................................... 20.3821 20.7275 21.2689 20.8164
360164...................................................... 16.1643 * * 16.1643
360165...................................................... 19.4831 18.2571 18.2417 18.6524
360166...................................................... 16.9778 18.7321 * 17.8568
360170...................................................... 17.1779 16.4653 20.4407 17.9153
360172...................................................... 18.4690 18.6720 19.8909 19.1486
360174...................................................... 19.0887 19.9725 20.5399 20.0142
360175...................................................... 20.4133 21.1685 21.5450 21.0739
360176...................................................... 15.4730 15.9430 16.6228 16.0305
360177...................................................... 19.4122 18.7898 18.9576 19.0368
360178...................................................... 17.3985 18.8704 16.7962 17.7254
360179...................................................... 19.1417 21.1309 20.7069 20.2966
360180...................................................... 22.0949 21.3826 21.0146 21.4888
360184...................................................... 19.3502 19.1224 * 19.2391
360185...................................................... 18.6697 18.7291 19.4858 18.9599
360186...................................................... 20.8579 18.3246 20.7572 19.9570
360187...................................................... 18.0209 18.5109 19.6535 18.7427
360188...................................................... 17.5327 17.1044 18.3057 17.6838
360189...................................................... 17.3713 17.8981 18.5940 17.9373
360192...................................................... 20.9980 21.6365 22.7846 21.8042
360193...................................................... 17.6874 * * 17.6874
360194...................................................... 17.6890 17.1884 17.6140 17.4968
360195...................................................... 19.0173 19.9302 20.5828 19.8368
360197...................................................... 19.4250 20.0603 20.5062 19.9981
360200...................................................... 17.7583 16.2306 17.9623 17.3129
360203...................................................... 15.6212 16.3181 15.9609 15.9716
360204...................................................... 19.3543 22.2494 * 20.5754
360210...................................................... 20.2809 20.9955 21.8629 21.0428
360211...................................................... 19.5762 19.9895 20.6081 20.0860
360212...................................................... 20.2288 21.1123 20.6987 20.6781
360213...................................................... 18.3253 19.4765 19.0584 18.9547
360218...................................................... 18.4140 18.9469 18.8204 18.7231
360230...................................................... 21.4385 21.9763 20.8042 21.3850
360231...................................................... 13.5586 12.9588 14.4168 13.6102
360234...................................................... 22.4324 23.2588 20.6131 22.0967
360236...................................................... 19.4881 17.8426 21.4628 19.5088
360239...................................................... 19.8584 20.1854 19.2375 19.7767
360241...................................................... 22.0795 23.5318 25.3741 23.5406
360243...................................................... 13.5835 14.8694 * 14.2018
360244...................................................... 10.5518 * * 10.5518
360245...................................................... 15.0579 16.4622 15.9782 15.8310
360247...................................................... 18.1116 16.3092 17.0776 17.0967
360248...................................................... 21.6499 * * 21.6499
360249...................................................... * * 25.4331 25.4331
370001...................................................... 21.2714 22.5214 24.1929 22.6419
370002...................................................... 14.0847 14.7315 15.4333 14.7194
370004...................................................... 16.7671 19.3236 18.5233 18.1546
370005...................................................... 17.3817 15.1654 15.3881 15.9167
370006...................................................... 12.9493 16.6484 16.4995 15.3118
[[Page 40012]]
370007...................................................... 17.1535 15.2905 15.8312 16.0498
370008...................................................... 17.3048 16.6566 17.5553 17.1688
370011...................................................... 14.6397 14.9701 15.6178 15.0345
370012...................................................... 10.8003 11.7265 12.4942 11.6228
370013...................................................... 18.0385 19.3398 18.9584 18.7911
370014...................................................... 19.6543 20.6512 20.2858 20.2276
370015...................................................... 17.8247 17.0319 20.8765 18.5256
370016...................................................... 16.6401 19.1191 19.1613 18.3470
370017...................................................... 12.9837 12.6400 13.6531 13.1239
370018...................................................... 14.2438 18.5107 17.7054 16.6955
370019...................................................... 16.8801 14.2277 14.6216 15.1546
370020...................................................... 13.4787 14.3798 15.1035 14.3356
370021...................................................... 11.2639 12.0474 12.9030 12.0738
370022...................................................... 17.9015 17.2344 17.3724 17.4872
370023...................................................... 16.8215 17.7630 17.5148 17.3665
370025...................................................... 16.3970 17.4988 18.4815 17.4661
370026...................................................... 16.8991 18.3371 18.0412 17.7563
370028...................................................... 19.7118 18.4445 21.1292 19.7322
370029...................................................... 13.8930 16.4924 18.2580 16.0663
370030...................................................... 15.4736 16.3269 16.5803 16.1058
370032...................................................... 16.6432 18.2821 18.1538 17.7030
370033...................................................... 12.3910 13.5216 11.3210 12.4595
370034...................................................... 14.5101 15.6386 15.6288 15.2811
370035...................................................... 18.9629 25.5764 * 21.9610
370036...................................................... 11.4593 12.4026 12.4070 12.0833
370037...................................................... 17.7491 16.7012 18.9556 17.7764
370038...................................................... 12.8135 13.3084 13.0210 13.0660
370039...................................................... 16.2661 15.5206 19.4498 17.0406
370040...................................................... 14.2582 14.4672 15.5109 14.7638
370041...................................................... 17.4123 16.7356 16.2316 16.8488
370042...................................................... 14.6146 14.9175 15.2764 14.9764
370043...................................................... 16.0764 15.9534 17.0892 16.3549
370045...................................................... 12.4352 10.1994 11.3560 11.2236
370046...................................................... 18.1499 18.8334 * 18.4831
370047...................................................... 15.6716 16.7554 17.8769 16.7444
370048...................................................... 17.4356 18.2150 15.6803 17.1206
370049...................................................... 19.8397 20.7176 19.4868 19.9892
370051...................................................... 12.1816 11.6736 12.5171 12.1083
370054...................................................... 16.5598 16.9049 18.0787 17.1343
370056...................................................... 18.8774 18.4558 18.1432 18.4804
370057...................................................... 14.6564 16.7261 15.1228 15.5054
370059...................................................... 16.4578 18.1386 18.3314 17.6259
370060...................................................... 15.1169 16.5403 19.3051 16.8157
370063...................................................... 17.0645 14.4132 16.7342 16.0603
370064...................................................... 8.7499 10.9676 11.9954 10.6741
370065...................................................... 16.5638 16.6898 18.1349 17.1281
370071...................................................... 14.9472 16.1439 16.4567 15.8354
370072...................................................... 14.6497 14.4742 13.6519 14.2760
370076...................................................... 12.8568 13.5694 14.3555 13.5818
370077...................................................... 17.6236 * * 17.6236
370078...................................................... 17.2370 18.4086 19.2412 18.2505
370079...................................................... 13.5976 16.6861 16.9201 15.7005
370080...................................................... 14.3445 13.9239 14.7323 14.3058
370082...................................................... 13.5434 13.9634 15.0669 14.1855
370083...................................................... 11.4905 13.1519 13.1810 12.6268
370084...................................................... 21.7484 22.0545 13.1197 17.8063
370085...................................................... 11.8844 11.2842 48.1271 14.9179
370086...................................................... 13.5646 15.4404 11.1900 13.1933
370089...................................................... 14.4968 16.0966 17.2638 15.9758
370091...................................................... 17.5839 19.1698 20.1822 18.9743
370092...................................................... 14.6757 14.9802 15.7678 15.1529
370093...................................................... 18.5747 18.4600 19.7008 19.0469
370094...................................................... 18.3796 18.0002 19.5462 18.6588
[[Page 40013]]
370095...................................................... 14.1319 12.6383 13.4202 13.3755
370097...................................................... 23.3116 22.9714 23.2056 23.1716
370099...................................................... 16.2649 15.4549 19.4646 16.8783
370100...................................................... 17.1036 14.0168 18.8274 16.6764
370103...................................................... 15.8967 19.2353 18.2685 17.7516
370105...................................................... 17.6811 21.3352 20.7890 19.9853
370106...................................................... 18.6238 18.5485 20.3651 19.1398
370108...................................................... 12.2379 12.3279 12.7470 12.4421
370112...................................................... 15.2488 14.8539 15.3039 15.1287
370113...................................................... 16.2043 16.1046 17.6107 16.6143
370114...................................................... 15.9801 16.5268 17.8941 16.8136
370121...................................................... 19.5506 22.5611 21.3099 21.1472
370122...................................................... 12.1514 15.0645 15.4375 13.9736
370123...................................................... 16.3609 18.9159 19.0313 18.0343
370125...................................................... 13.5453 15.6284 13.9436 14.3107
370126...................................................... 18.2447 23.9654 15.8020 19.1824
370131...................................................... 16.2403 17.5689 15.7261 16.4650
370133...................................................... 10.0169 10.9575 12.9545 11.1921
370138...................................................... 15.9372 16.4005 17.5551 16.6500
370139...................................................... 13.3023 14.8612 14.9964 14.3624
370140...................................................... 15.2265 16.0721 17.1393 16.1657
370141...................................................... 12.1420 18.4101 20.7798 16.3574
370146...................................................... 12.5581 12.6402 13.0399 12.7467
370148...................................................... 16.4147 20.6458 20.6612 19.2220
370149...................................................... 16.7218 16.1850 17.0929 16.6647
370153...................................................... 15.3218 17.8352 16.4669 16.5507
370154...................................................... 15.9128 15.5127 15.6093 15.6789
370156...................................................... 13.6363 13.9255 14.5696 14.0273
370158...................................................... 15.0865 15.6917 15.6994 15.4906
370159...................................................... 17.8319 28.0536 21.1267 21.7006
370163...................................................... 14.5609 17.6361 20.4217 17.2893
370165...................................................... 13.2174 13.0910 13.0375 13.1156
370166...................................................... 17.8154 17.2849 21.0797 18.6456
370169...................................................... 9.4807 12.5243 12.7138 11.5273
370176...................................................... 16.0355 15.9476 18.9951 16.9629
370177...................................................... 11.8757 11.2536 14.6481 12.5743
370178...................................................... 11.6384 10.5726 11.6200 11.2422
370179...................................................... 19.2677 17.2829 21.3002 18.9651
370183...................................................... 7.6164 10.2945 16.9318 11.0088
370186...................................................... 13.3454 13.6192 15.4533 14.1321
370190...................................................... 13.7032 14.1397 19.3570 15.3737
370192...................................................... 16.7402 18.4614 19.6967 18.2866
370197...................................................... 21.5718 * * 21.5718
370198...................................................... * 21.3136 * 21.3136
370200...................................................... * * 22.5299 22.5299
380001...................................................... 22.0255 20.3127 26.4822 22.5494
380002...................................................... 19.4764 24.0241 21.9185 21.9840
380003...................................................... 24.7434 21.7826 20.9007 22.2865
380004...................................................... 23.1432 23.1451 23.3609 23.2208
380005...................................................... 23.2415 24.0838 25.0750 24.1485
380006...................................................... 20.5375 21.2731 21.3520 21.0653
380007...................................................... 24.2933 25.2995 32.2678 27.0282
380008...................................................... 21.1888 20.7063 22.3004 21.4082
380009...................................................... 25.1702 23.8104 24.3851 24.4234
380010...................................................... 19.7477 23.7488 22.7276 21.8451
380011...................................................... 21.1353 21.1151 20.3357 20.8683
380013...................................................... 20.1038 18.6818 19.8180 19.5721
380014...................................................... 23.4819 24.6574 25.9828 24.7413
380017...................................................... 23.8231 26.0578 25.3954 25.0552
380018...................................................... 22.0776 22.3525 22.9822 22.4971
380019...................................................... 20.7700 22.1215 20.8176 21.2209
380020...................................................... 21.3556 20.1464 22.9568 21.5448
380021...................................................... 20.6358 21.1590 23.8499 21.8371
[[Page 40014]]
380022...................................................... 21.6110 22.6408 24.5974 22.8841
380023...................................................... 19.2357 20.5462 21.3831 20.3976
380025...................................................... 24.6738 26.3652 26.9346 25.9824
380026...................................................... 19.2663 20.4706 20.6972 20.1525
380027...................................................... 20.1576 20.8647 21.5490 20.8958
380029...................................................... 18.5699 19.4246 20.1471 19.4015
380031...................................................... 22.8346 23.3181 20.3396 22.1492
380033...................................................... 23.2881 25.2454 27.1343 25.1500
380035...................................................... 21.6533 22.4099 23.9719 22.6232
380036...................................................... 19.3269 27.1587 27.2157 23.8613
380037...................................................... 21.2347 21.9158 22.1774 21.7911
380038...................................................... 25.5750 26.0869 26.7759 26.1419
380039...................................................... 22.1235 23.1746 22.8048 22.6937
380040...................................................... 21.6378 26.2717 22.5477 23.4095
380042...................................................... 19.8096 21.1176 24.4172 21.7244
380047...................................................... 21.9511 23.0718 24.2524 23.1258
380048...................................................... 18.3847 17.5885 18.3005 18.0671
380050...................................................... 18.2486 20.3934 20.3205 19.6254
380051...................................................... 21.2358 22.3568 22.3207 21.9927
380052...................................................... 17.8741 19.4570 18.6299 18.6300
380055...................................................... 21.2459 * * 21.2459
380056...................................................... 17.1600 19.5185 18.4961 18.3892
380060...................................................... 23.2923 24.2670 24.2059 23.9182
380061...................................................... 22.5983 22.3736 22.8781 22.6217
380062...................................................... 18.5229 20.7716 18.2148 19.1910
380063...................................................... 19.3566 20.4077 * 19.9113
380064...................................................... 19.8719 19.9826 22.9160 20.8404
380065...................................................... 22.1706 26.1404 22.9608 23.6770
380066...................................................... 20.4189 22.0349 23.2794 21.9793
380068...................................................... 22.7573 22.3178 * 22.5559
380069...................................................... 19.5793 19.8300 20.4882 19.9809
380070...................................................... 24.7116 27.2541 27.7790 26.6130
380071...................................................... 20.4707 22.6386 25.1808 22.8743
380072...................................................... 16.3169 19.1553 19.4346 18.3236
380075...................................................... 22.1703 22.3625 22.4139 22.3203
380078...................................................... 19.1035 20.2507 21.0903 20.1439
380081...................................................... 20.5902 20.9882 20.4082 20.6790
380082...................................................... 22.5856 22.2275 22.9606 22.5990
380083...................................................... 21.8096 21.3859 21.7431 21.6440
380084...................................................... 23.6412 24.2844 27.1689 24.9815
380087...................................................... 14.0976 16.5309 17.0380 15.8783
380088...................................................... 19.5204 21.5225 19.5346 20.1728
380089...................................................... 23.7413 19.5255 25.2908 23.0572
380090...................................................... 27.0867 29.2702 24.9351 26.9453
380091...................................................... 22.8333 27.5560 25.3062 25.1774
390001...................................................... 18.6384 19.2989 19.6732 19.2277
390002...................................................... 18.0787 21.8353 19.7833 19.8184
390003...................................................... 17.2435 17.1371 18.1025 17.4798
390004...................................................... 18.8899 19.2277 20.3204 19.4755
390005...................................................... 16.4459 17.3506 16.9472 16.9256
390006...................................................... 19.6012 20.2959 21.1786 20.3254
390007...................................................... 21.4093 21.7506 21.3839 21.5152
390008...................................................... 16.7440 17.8297 18.2743 17.6097
390009...................................................... 20.1181 20.6507 20.6241 20.4567
390010...................................................... 17.2315 17.5127 17.3335 17.3583
390011...................................................... 18.0683 18.1717 18.3257 18.1941
390012...................................................... 20.0227 20.6523 21.0610 20.5672
390013...................................................... 19.3300 19.2698 19.6562 19.4200
390015...................................................... 12.9372 13.1337 13.7352 13.2647
390016...................................................... 17.0679 16.9892 17.1133 17.0565
390017...................................................... 16.2170 16.7493 18.6113 17.1752
390018...................................................... 19.1241 21.3626 19.0279 19.8558
390019...................................................... 16.3965 16.7848 17.7258 16.9784
[[Page 40015]]
390022...................................................... 22.8967 21.5064 24.8468 23.0587
390023...................................................... 19.5639 21.8270 22.1044 21.4167
390024...................................................... 25.0359 24.9437 25.4606 25.1433
390025...................................................... 15.7111 15.6155 15.5523 15.6287
390026...................................................... 22.7645 22.3902 22.9718 22.7143
390027...................................................... 27.6893 26.8878 29.5940 28.0411
390028...................................................... 20.1087 22.7700 23.6571 22.0510
390029...................................................... 19.6883 21.5729 21.2661 20.8012
390030...................................................... 18.3978 17.9580 18.6887 18.3432
390031...................................................... 19.5175 19.2755 18.8162 19.2068
390032...................................................... 18.1492 17.8041 21.5105 19.0439
390035...................................................... 18.5146 20.2029 22.3591 20.2740
390036...................................................... 18.8657 19.9880 19.7671 19.5278
390037...................................................... 22.2359 21.0616 20.4263 21.2243
390039...................................................... 16.5438 17.1046 17.5300 17.0475
390040...................................................... 15.1211 15.9612 16.6876 15.9078
390041...................................................... 19.5760 19.8080 20.4397 19.9243
390042...................................................... 21.1276 22.7693 22.5775 22.1662
390043...................................................... 16.3561 17.2607 17.4764 17.0230
390044...................................................... 19.5419 20.2813 20.9831 20.2788
390045...................................................... 18.4591 18.5574 19.4677 18.8305
390046...................................................... 20.4608 20.7303 21.7445 20.9727
390047...................................................... 24.5824 27.6661 26.9709 26.2900
390048...................................................... 18.3801 19.0920 19.7992 19.0527
390049...................................................... 21.1318 21.1217 22.1586 21.4802
390050...................................................... 20.9240 22.8808 22.2639 22.0253
390051...................................................... 26.0485 25.7910 28.1385 26.5675
390052...................................................... 17.0988 20.9306 20.1195 19.3733
390054...................................................... 17.4382 17.8852 18.4975 17.9431
390055...................................................... 25.8961 24.2211 23.4017 24.4911
390056...................................................... 17.1692 17.7858 19.3901 18.0977
390057...................................................... 19.7459 20.2059 20.2395 20.0600
390058...................................................... 19.2543 19.7379 20.3520 19.7916
390060...................................................... 13.6276 * * 13.6276
390061...................................................... 20.4819 21.2392 23.8722 21.8310
390062...................................................... 16.4505 16.6721 17.3750 16.8291
390063...................................................... 19.6373 20.0125 19.4965 19.7211
390065...................................................... 20.0001 19.9361 20.0473 19.9948
390066...................................................... 18.7064 19.8539 18.9296 19.1567
390067...................................................... 20.6515 20.9688 20.8162 20.8116
390068...................................................... 17.5524 18.3158 19.1109 18.3267
390069...................................................... 19.2858 19.6466 * 19.4555
390070...................................................... 20.1862 16.1988 21.8549 19.3957
390071...................................................... 16.2298 15.7165 16.0100 15.9856
390072...................................................... 15.5565 16.3133 16.9232 16.2264
390073...................................................... 20.6859 20.5581 21.2623 20.8422
390074...................................................... 16.5971 18.4806 18.3093 17.7465
390075...................................................... 17.2676 17.9840 18.7695 17.9105
390076...................................................... 21.4307 20.2475 21.3290 20.9889
390078...................................................... 18.2328 19.2089 19.0156 18.8052
390079...................................................... 18.1969 18.3312 18.9269 18.4731
390080...................................................... 19.5180 18.8028 21.4707 19.8661
390081...................................................... 23.9922 24.8351 24.7461 24.5194
390083...................................................... 20.5919 * * 20.5919
390084...................................................... 16.3463 16.4026 20.2529 17.4556
390086...................................................... 17.2481 18.5265 18.3563 18.0522
390088...................................................... 23.4941 23.6173 23.9506 23.6668
390090...................................................... 20.6463 21.6437 21.3759 21.2068
390091...................................................... 18.3746 18.1569 18.3770 18.3019
390093...................................................... 16.6336 17.7171 18.4442 17.6019
390095...................................................... 13.0459 16.3357 16.6930 15.2335
390096...................................................... 19.3118 19.1171 22.4382 20.4516
390097...................................................... 21.4115 23.5963 25.2845 23.2449
[[Page 40016]]
390100...................................................... 20.3014 20.7859 20.9263 20.6729
390101...................................................... 17.0534 17.9499 18.5039 17.8169
390102...................................................... 19.4924 19.0461 21.5496 20.0293
390103...................................................... 17.7054 18.4312 18.8667 18.3176
390104...................................................... 15.9605 15.9008 16.3255 16.0548
390106...................................................... 16.2783 16.6666 16.8439 16.6044
390107...................................................... 19.1793 19.5178 20.9841 19.9123
390108...................................................... 21.2872 21.0899 21.3142 21.2288
390109...................................................... 14.6645 16.4597 16.5299 15.8639
390110...................................................... 21.3191 21.5282 21.6464 21.5043
390111...................................................... 28.7875 27.5193 33.3971 29.8383
390112...................................................... 14.0439 14.9427 15.0065 14.6808
390113...................................................... 17.9377 19.1945 19.3634 18.8262
390114...................................................... 22.9698 19.6295 20.9533 21.1250
390115...................................................... 24.7244 23.3461 21.4287 23.0792
390116...................................................... 20.6016 21.4877 21.3671 21.1457
390117...................................................... 16.9036 17.9393 18.0769 17.6425
390118...................................................... 16.8962 18.3440 18.9507 18.0638
390119...................................................... 18.5935 18.2951 18.8815 18.5863
390121...................................................... 18.6422 20.8780 19.1315 19.5644
390122...................................................... 17.4645 17.1902 17.7734 17.4764
390123...................................................... 20.8412 20.8344 21.3974 21.0254
390125...................................................... 15.9356 16.7983 17.5446 16.7393
390126...................................................... 20.9383 20.6498 * 20.8020
390127...................................................... 21.8849 21.7724 22.4555 22.0398
390128...................................................... 19.4132 19.6792 19.3165 19.4699
390130...................................................... 17.3253 17.7049 18.3695 17.7936
390131...................................................... 16.8349 16.0986 19.2096 17.3202
390132...................................................... 20.5528 21.1931 22.8414 21.4849
390133...................................................... 24.6131 23.3489 24.7561 24.1960
390135...................................................... 21.2497 21.5782 22.1905 21.6491
390136...................................................... 17.6128 16.9737 20.6286 18.3801
390137...................................................... 16.5598 17.5687 18.5397 17.5480
390138...................................................... 18.8601 19.6212 20.6936 19.7394
390139...................................................... 22.9351 24.4515 23.9757 23.7712
390142...................................................... 26.7954 26.8086 28.8877 27.5656
390145...................................................... 20.3393 20.3731 20.4228 20.3787
390146...................................................... 17.7020 18.7922 18.6505 18.3503
390147...................................................... 21.1085 20.9651 21.2492 21.1067
390150...................................................... 19.6575 20.7294 20.3155 20.2474
390151...................................................... 20.5084 21.6000 22.5206 21.5535
390152...................................................... 19.1525 20.3353 19.4017 19.6203
390153...................................................... 23.1183 23.7013 22.9707 23.2621
390154...................................................... 15.8478 17.4036 16.7052 16.6538
390156...................................................... 21.1629 21.8498 22.6398 21.8660
390157...................................................... 19.8268 19.6578 19.1783 19.5633
390158...................................................... 21.6045 * * 21.6045
390160...................................................... 20.7676 21.4810 19.4463 20.4967
390161...................................................... 12.3743 16.4799 * 14.3389
390162...................................................... 21.0228 21.4095 21.9188 21.4386
390163...................................................... 15.6227 16.8013 17.7564 16.7297
390164...................................................... 21.5890 24.6765 24.9750 23.5327
390166...................................................... 19.9612 19.0405 19.7978 19.5957
390167...................................................... 22.9136 19.8973 * 21.3982
390168...................................................... 18.9936 18.7400 18.8863 18.8736
390169...................................................... 18.9878 20.2382 22.0547 20.4487
390170...................................................... 22.9877 26.5891 24.7973 24.6450
390173...................................................... 17.8568 18.5370 18.6613 18.3502
390174...................................................... 25.2407 25.4189 25.3307 25.3310
390176...................................................... 17.3577 17.8740 20.8368 18.6587
390178...................................................... 17.7036 16.6993 17.0534 17.1490
390179...................................................... 21.4093 21.6901 21.8593 21.6579
390180...................................................... 25.1191 25.7074 26.5541 25.8271
[[Page 40017]]
390181...................................................... 17.0860 19.4654 19.3832 18.6237
390183...................................................... 19.0834 17.8306 17.9848 18.2942
390184...................................................... 20.7489 20.8060 20.9349 20.8256
390185...................................................... 17.6516 18.8798 20.3877 18.9752
390189...................................................... 18.6668 20.0889 20.3338 19.6907
390191...................................................... 16.1993 16.3240 17.2270 16.5760
390192...................................................... 16.3696 17.4537 17.6597 17.1476
390193...................................................... 16.4663 16.7874 18.1209 17.0634
390194...................................................... 20.1547 20.7953 21.2689 20.7092
390195...................................................... 23.6920 24.6855 24.1793 24.1876
390197...................................................... 18.9857 19.2690 20.7998 19.6927
390198...................................................... 15.4508 15.9721 15.8833 15.7671
390199...................................................... 16.6644 17.0515 17.3865 17.0306
390200...................................................... 13.5898 15.1399 15.4012 14.7971
390201...................................................... 20.5011 20.6296 20.3533 20.4916
390203...................................................... 21.1895 20.9432 21.4989 21.2088
390204...................................................... 20.8483 20.1779 22.9616 21.3067
390206...................................................... 18.5746 18.4027 * 18.4910
390209...................................................... 16.9558 17.4792 18.7059 17.7155
390211...................................................... 17.9132 17.8638 18.4213 18.0846
390213...................................................... 17.4453 18.8555 19.1553 18.5312
390215...................................................... 21.4291 20.7084 21.2032 21.1048
390217...................................................... 19.2926 19.1406 19.9837 19.4647
390219...................................................... 21.6295 18.8292 19.6226 19.9600
390220...................................................... 18.5178 18.7178 17.7916 18.3301
390222...................................................... 20.9080 21.5739 22.1548 21.5483
390223...................................................... 22.6498 23.6482 22.1775 22.7892
390224...................................................... 15.9058 15.3015 13.7518 14.9518
390225...................................................... 18.1752 18.6125 18.7290 18.5053
390226...................................................... 23.1638 21.8268 21.8481 22.2835
390228...................................................... 19.8129 19.4083 19.8180 19.6802
390231...................................................... 24.4852 22.7544 19.4798 21.9903
390233...................................................... 18.7707 19.4887 20.2309 19.5042
390235...................................................... 24.6044 25.0857 21.4200 24.0078
390236...................................................... 17.0339 16.2397 17.8735 17.0494
390237...................................................... 21.7479 19.5230 22.3011 21.1430
390238...................................................... * 17.8211 17.1055 17.4821
390242...................................................... 18.0943 * * 18.0943
390244...................................................... 14.4133 15.4611 15.6402 15.1810
390245...................................................... 20.1544 26.0194 24.5076 23.4886
390246...................................................... 17.9214 18.9733 25.0556 20.2904
390247...................................................... 20.6671 20.9526 21.2151 20.8919
390249...................................................... 10.7336 12.7920 13.1657 12.2298
390256...................................................... 23.7828 20.9469 22.2773 22.2601
390258...................................................... 21.3629 21.9207 22.6852 21.9998
390260...................................................... 21.1917 21.9509 21.5982 21.5728
390262...................................................... 18.6684 18.2379 * 18.4504
390263...................................................... 20.0939 20.6855 20.3796 20.3890
390265...................................................... 19.5089 20.3580 20.4950 20.1207
390266...................................................... 16.2372 17.1666 17.1966 16.8552
390267...................................................... 20.5125 21.2974 19.2665 20.4773
390268...................................................... 21.0161 21.3486 22.0909 21.4791
390270...................................................... 17.8280 19.0925 19.2074 18.7055
390277...................................................... 27.0983 * * 27.0983
390278...................................................... 19.2019 18.2865 17.7176 18.4620
390279...................................................... 13.6992 14.3241 14.8655 14.2998
390283...................................................... * * 22.5490 22.5490
390284...................................................... * * 34.3904 34.3904
400001...................................................... 9.8615 9.9463 10.5757 10.1359
400002...................................................... 9.3063 10.1417 13.0494 10.8249
400003...................................................... 9.9865 10.8821 12.4078 11.0633
400004...................................................... 8.4811 8.9864 8.5648 8.6695
400005...................................................... 7.8494 9.5632 7.7432 8.3858
[[Page 40018]]
400006...................................................... 10.5281 10.3444 10.1048 10.3288
400007...................................................... 7.8637 6.4490 8.0174 7.3754
400009...................................................... 8.3727 8.4207 8.8650 8.5497
400010...................................................... 11.6642 10.6518 10.8011 10.9779
400011...................................................... 5.6825 7.4979 8.5426 7.2512
400012...................................................... 7.8134 8.2412 8.4728 8.1883
400013...................................................... 8.2066 8.4579 9.2624 8.6839
400014...................................................... 9.5354 9.5235 9.4798 9.5126
400015...................................................... 10.3326 10.9505 14.4076 11.3577
400016...................................................... 12.0743 13.2756 13.3922 12.9125
400017...................................................... 8.5675 8.6421 9.2577 8.8024
400018...................................................... 9.4534 10.4557 10.6208 10.1978
400019...................................................... 10.1512 10.4332 10.8940 10.5307
400021...................................................... 9.9121 10.6988 12.1434 10.9538
400022...................................................... 11.1204 11.5861 12.2199 11.6336
400024...................................................... 7.5594 7.8984 9.2409 8.1615
400026...................................................... 7.1236 5.6454 5.8335 6.1312
400027...................................................... 8.4862 9.5899 * 9.0120
400028...................................................... 8.3991 8.8597 9.1794 8.7817
400031...................................................... 9.7826 8.2660 * 8.9857
400032...................................................... 9.7291 10.5498 10.0448 10.1074
400044...................................................... 11.7484 11.9704 11.9486 11.8844
400048...................................................... 8.9224 9.1701 15.1405 10.3604
400061...................................................... 12.2770 12.4493 13.0988 12.5813
400079...................................................... 7.0830 * 9.7203 8.1082
400087...................................................... 10.3972 9.5097 9.8534 9.8687
400094...................................................... 7.8208 8.9116 7.9187 8.1829
400098...................................................... 7.2098 9.3308 9.7791 8.8630
400102...................................................... 7.7288 9.8536 9.9903 9.1668
400103...................................................... 10.7316 11.2069 11.5359 11.1167
400104...................................................... 9.9416 11.0672 10.7292 10.5214
400105...................................................... 10.1726 9.3049 9.0556 9.5335
400106...................................................... 8.5143 9.3123 9.2187 9.0108
400109...................................................... 10.1786 10.9826 11.8760 11.0486
400110...................................................... 10.5250 10.3326 10.5277 10.4760
400111...................................................... 9.5600 9.5583 10.9665 10.1021
400112...................................................... 12.8478 10.1755 10.8694 11.2941
400113...................................................... 9.4835 9.2238 8.3168 9.0068
400114...................................................... 6.4076 9.0496 7.0510 7.4630
400115...................................................... 9.1311 9.8244 8.5487 9.1780
400117...................................................... 10.0381 10.2295 10.8756 10.3823
400118...................................................... 8.6964 9.4398 11.4051 9.9004
400120...................................................... 9.7425 9.5274 10.6584 9.9956
400121...................................................... 7.1061 7.8052 9.8322 8.2686
400122...................................................... 8.4806 8.1911 7.6413 8.0571
400123...................................................... 9.0217 7.8099 10.2367 9.0130
400124...................................................... 11.4839 12.0999 12.2452 11.9729
400125...................................................... * * 10.2056 10.2056
410001...................................................... 22.5322 23.2808 23.1738 23.0006
410004...................................................... 22.3212 22.4801 21.0638 22.0103
410005...................................................... 21.2407 23.1444 22.7170 22.3365
410006...................................................... 21.9798 23.3968 23.8700 23.0621
410007...................................................... 20.9489 22.1452 23.1325 22.1106
410008...................................................... 22.6133 23.0662 24.9726 23.5244
410009...................................................... 24.0769 24.4899 24.3895 24.3200
410010...................................................... 27.1426 26.9813 28.4589 27.5328
410011...................................................... 24.3676 25.2926 26.1183 25.2512
410012...................................................... 21.3337 24.5811 24.1695 23.4018
410013...................................................... 25.0050 24.5122 24.8800 24.7951
420002...................................................... 20.2049 19.4845 20.7804 20.1513
420004...................................................... 19.4079 19.7968 20.9588 20.0732
420005...................................................... 15.9906 17.3510 17.9694 17.1171
420006...................................................... 18.2374 18.3439 19.1760 18.5687
[[Page 40019]]
420007...................................................... 17.5783 18.2096 18.6456 18.1319
420009...................................................... 17.2515 18.5456 19.9586 18.6114
420010...................................................... 17.9141 17.1184 18.0252 17.6914
420011...................................................... 14.9944 16.5664 18.0970 16.4913
420014...................................................... 16.7219 16.6065 18.0519 17.0894
420015...................................................... 17.1802 18.8411 20.1164 18.5841
420016...................................................... 18.1451 15.6241 15.5485 16.2939
420018...................................................... 19.7285 19.7367 21.8775 20.3791
420019...................................................... 15.5521 16.9990 17.1726 16.5419
420020...................................................... 17.9011 20.9449 20.3193 19.6942
420023...................................................... 20.9663 19.4855 20.4053 20.2598
420026...................................................... 21.8968 20.3476 21.8749 21.3678
420027...................................................... 18.0774 18.8457 19.2594 18.7307
420029...................................................... 18.3557 * * 18.3557
420030...................................................... 17.8215 19.1453 20.6448 19.3038
420031...................................................... 13.0718 14.1855 8.2516 11.1227
420033...................................................... 21.0863 21.7279 23.1303 21.9705
420036...................................................... 19.7421 17.6136 21.3222 19.4565
420037...................................................... 21.9603 21.7908 22.7099 22.1669
420038...................................................... 16.1498 17.6726 18.6568 17.4393
420039...................................................... 16.9646 15.8385 18.3017 17.0260
420042...................................................... 14.6567 * * 14.6567
420043...................................................... 18.3607 19.4521 19.7570 19.1785
420048...................................................... 18.0286 18.4367 18.8070 18.4223
420049...................................................... 19.2340 17.5854 19.4049 18.7208
420051...................................................... 18.2518 19.5001 19.1555 18.9941
420053...................................................... 16.5452 16.9599 18.1657 17.1887
420054...................................................... 16.5474 18.2702 20.2574 18.3229
420055...................................................... 16.1823 19.2048 16.8717 17.3777
420056...................................................... 15.5966 14.8695 15.1835 15.1636
420057...................................................... 14.5006 15.9849 20.5266 17.2252
420059...................................................... 19.1303 15.8160 17.1483 17.3325
420061...................................................... 16.1310 16.5555 17.3543 16.6881
420062...................................................... 18.9513 17.8205 21.7469 19.4924
420064...................................................... 15.4531 16.7227 16.0794 16.0985
420065...................................................... 19.0645 19.6902 19.9435 19.5673
420066...................................................... 15.5001 15.1804 18.0042 16.2261
420067...................................................... 18.3106 18.8610 19.7824 19.0239
420068...................................................... 17.2144 18.5030 18.5481 18.0958
420069...................................................... 16.3189 17.0788 18.1298 17.2134
420070...................................................... 17.4486 18.0057 17.3876 17.6174
420071...................................................... 18.2878 19.4482 20.3902 19.3836
420072...................................................... 12.6013 13.8550 15.0158 13.8117
420073...................................................... 19.2011 19.1604 19.9986 19.4566
420074...................................................... 13.8038 16.9292 18.0967 16.2019
420075...................................................... 16.2946 14.2931 12.8158 14.3372
420078...................................................... 20.6818 20.7317 21.9082 21.1259
420079...................................................... 18.7710 20.8639 21.0874 20.2636
420080...................................................... 24.8321 22.3443 21.9968 22.9897
420081...................................................... 20.4211 * * 20.4211
420082...................................................... 18.8848 20.4653 21.7210 20.3535
420083...................................................... 23.3425 20.1472 22.6376 21.9902
420085...................................................... 18.5502 19.9603 21.6791 20.1188
420086...................................................... 19.3054 25.7179 20.2878 21.4636
420087...................................................... 18.4016 19.1403 19.8388 19.1412
420088...................................................... 17.9063 17.1938 19.9919 18.3046
420089...................................................... 21.6608 20.2537 20.5360 20.7623
420091...................................................... 18.5723 18.8687 20.3092 19.2195
420093...................................................... 16.7734 17.4689 18.3902 17.5654
420094...................................................... 32.6768 * * 32.6768
430004...................................................... 17.8435 18.5438 19.6344 18.6310
430005...................................................... 15.8449 16.3059 16.4560 16.2068
430007...................................................... 14.0586 14.1078 14.6331 14.2620
[[Page 40020]]
430008...................................................... 16.7640 17.6640 18.1323 17.5240
430010...................................................... 16.1093 17.1766 19.8191 17.5891
430011...................................................... 16.4234 16.9848 17.4750 16.9703
430012...................................................... 17.7809 17.2775 17.6997 17.5855
430013...................................................... 17.2424 18.1338 18.4817 17.9391
430014...................................................... 18.4417 16.8925 20.2387 18.3922
430015...................................................... 16.4123 18.0019 18.2875 17.5236
430016...................................................... 18.9715 19.4759 20.8850 19.7559
430018...................................................... 14.9100 14.8854 16.2244 15.3323
430022...................................................... 12.9532 13.4905 14.5118 13.6222
430023...................................................... 11.6383 12.2331 16.2164 13.2302
430024...................................................... 13.9942 15.4709 16.1801 15.3449
430026...................................................... 10.8532 * * 10.8532
430027...................................................... 18.6367 19.1461 20.2591 19.2968
430028...................................................... 16.7185 18.2312 17.1577 17.3522
430029...................................................... 15.1010 16.6500 17.6986 16.5066
430031...................................................... 12.4631 13.1258 12.4660 12.6792
430033...................................................... 14.6423 15.3003 17.3652 15.6688
430034...................................................... 12.8513 15.4064 14.2491 14.1740
430036...................................................... 13.7807 13.6967 15.6258 14.3461
430037...................................................... 15.9545 16.5368 18.1293 16.8632
430038...................................................... 11.9419 13.7167 18.4078 14.2118
430040...................................................... 13.3722 13.6745 14.4509 13.8057
430041...................................................... 12.6235 13.1936 14.8816 13.4964
430043...................................................... 13.4288 13.6908 14.9949 14.0204
430044...................................................... 16.4488 18.4970 21.0823 18.5195
430047...................................................... 15.6227 17.4956 17.9823 16.9377
430048...................................................... 17.2589 18.3524 18.7602 18.0996
430049...................................................... 14.4354 15.5381 15.2237 15.0640
430051...................................................... 17.2139 17.0574 18.8070 17.6987
430054...................................................... 13.5011 14.7251 14.8003 14.3524
430056...................................................... 11.4117 11.7627 10.3697 11.1792
430057...................................................... 15.1516 15.4390 17.2805 15.9601
430060...................................................... 8.6409 9.0358 10.0176 9.2343
430062...................................................... 10.8879 * * 10.8879
430064...................................................... 12.7394 14.4367 14.2184 13.7779
430065...................................................... 12.7660 * * 12.7660
430066...................................................... 13.4380 14.3557 15.6660 14.4524
430073...................................................... 14.9784 16.1133 15.3776 15.4839
430076...................................................... 12.2452 12.7608 13.9883 12.9521
430077...................................................... 17.7126 19.3012 19.8558 18.9586
430079...................................................... 12.9780 13.6836 14.1815 13.5924
430087...................................................... 10.4491 * * 10.4491
430089...................................................... 17.0065 17.8908 17.9790 17.6658
430090...................................................... * 21.5239 21.5974 21.5592
430091...................................................... * 19.2146 18.1567 18.5152
430092...................................................... * * 21.3807 21.3807
430093...................................................... * * 19.5013 19.5013
440001...................................................... 15.3134 14.8713 15.5897 15.2550
440002...................................................... 18.5411 19.1498 20.3740 19.3756
440003...................................................... 17.4736 18.3658 19.3042 18.3967
440006...................................................... 20.6559 19.6021 21.4055 20.5221
440007...................................................... 7.7632 12.1230 14.8959 11.0241
440008...................................................... 15.4701 17.2848 18.8994 17.1822
440009...................................................... 15.4558 17.8424 17.4831 16.9676
440010...................................................... 13.5118 19.9829 16.3283 16.4644
440011...................................................... 17.1591 17.6948 18.3375 17.7161
440012...................................................... 19.0606 15.9837 19.5739 18.2503
440014...................................................... 14.6093 15.9195 16.1143 15.5705
440015...................................................... 21.0884 18.2632 22.0659 20.4116
440016...................................................... 14.9409 15.4097 16.2964 15.5583
440017...................................................... 21.1258 19.6215 20.4563 20.3835
440018...................................................... 18.2080 16.4115 17.4995 17.3550
[[Page 40021]]
440019...................................................... 28.2242 20.0416 21.5402 22.7883
440020...................................................... 15.5889 18.1154 17.8879 17.2181
440022...................................................... 19.0214 15.8459 * 17.5909
440023...................................................... 14.1410 15.4721 16.7837 15.4038
440024...................................................... 18.1028 18.4432 18.4046 18.3183
440025...................................................... 15.2826 15.8784 16.3140 15.8395
440026...................................................... 22.9174 23.0550 23.2566 23.0549
440029...................................................... 18.5183 19.4326 20.7050 19.5797
440030...................................................... 15.5718 16.2941 16.9925 16.3267
440031...................................................... 14.3023 15.5432 17.0211 15.6197
440032...................................................... 13.5996 13.9775 13.8140 13.7931
440033...................................................... 14.0409 14.5304 13.7328 14.1227
440034...................................................... 17.9315 19.5470 20.0309 19.2030
440035...................................................... 18.1578 18.9026 19.3034 18.7862
440039...................................................... 19.3747 19.9439 21.6536 20.3424
440040...................................................... 17.4965 16.3740 16.9275 16.9214
440041...................................................... 13.6279 14.6621 14.9545 14.4249
440046...................................................... 16.8798 18.1654 19.3229 18.0984
440047...................................................... 17.0037 16.6646 17.8092 17.1528
440048...................................................... 18.1449 19.4498 21.4993 19.5981
440049...................................................... 16.7066 17.9292 18.7967 17.8439
440050...................................................... 16.7627 19.1328 18.2511 18.0098
440051...................................................... 14.9074 13.1901 16.0421 14.6532
440052...................................................... 16.2693 16.6541 19.8075 17.4207
440053...................................................... 17.6873 18.5515 19.6494 18.6583
440054...................................................... 12.3134 13.8716 13.3967 13.1942
440056...................................................... 14.2534 15.9821 16.2742 15.4778
440057...................................................... 12.7190 12.7925 13.7257 13.0446
440058...................................................... 18.7381 18.8118 19.1878 18.9185
440059...................................................... 17.5274 18.5418 19.6018 18.6049
440060...................................................... 15.8599 18.0586 19.7916 17.7309
440061...................................................... 16.8442 14.9708 22.5525 17.8114
440063...................................................... 18.2923 19.3222 19.8371 19.1661
440064...................................................... 17.6154 17.7652 18.9809 18.1133
440065...................................................... 18.6943 18.5825 18.8296 18.7013
440067...................................................... 22.0655 16.2811 17.2397 18.2348
440068...................................................... 17.4513 19.4695 19.3668 18.7087
440070...................................................... 15.0440 13.7035 14.0437 14.2715
440071...................................................... 16.2691 17.0186 19.7836 17.5412
440072...................................................... 16.7675 17.5995 19.1522 17.8026
440073...................................................... 18.5576 19.1714 19.5554 19.1079
440078...................................................... 13.0916 15.0849 16.0188 14.6728
440081...................................................... 17.9702 18.3587 19.3454 18.5764
440082...................................................... 23.0805 22.2857 22.6855 22.6613
440083...................................................... 35.0978 14.8525 13.7423 17.4998
440084...................................................... 13.3678 13.4378 13.7731 13.5305
440091...................................................... 19.7250 19.6114 20.1065 19.8343
440100...................................................... 13.9487 13.8437 14.7113 14.1637
440102...................................................... 13.9575 14.3510 14.5500 14.2949
440103...................................................... 19.2083 20.3052 18.6990 19.3857
440104...................................................... 22.3883 22.4403 22.6754 22.4883
440105...................................................... 16.0338 16.7131 17.1172 16.6050
440109...................................................... 14.2491 16.0446 17.7443 15.8919
440110...................................................... 15.9174 21.1716 17.4816 17.9016
440111...................................................... 21.0682 23.2425 23.2254 22.5309
440114...................................................... 13.6095 14.4997 15.0036 14.3318
440115...................................................... 12.9668 17.4514 18.5457 16.2205
440120...................................................... 18.2993 17.2384 16.3115 17.2831
440125...................................................... 16.1067 15.6588 19.4115 17.0424
440130...................................................... 16.6750 17.8223 17.4857 17.3264
440131...................................................... 14.6752 15.5048 16.1214 15.4186
440132...................................................... 15.9069 16.6553 16.8871 16.4950
440133...................................................... 21.5116 21.5313 23.0891 22.0182
[[Page 40022]]
440135...................................................... 20.9029 19.2010 22.2005 20.8180
440137...................................................... 14.6966 14.5632 15.0070 14.7511
440141...................................................... 12.4774 13.5308 15.9429 13.7977
440142...................................................... 13.0059 15.7287 16.8855 15.0859
440143...................................................... 17.8429 17.7821 18.2061 17.9416
440144...................................................... 16.6666 17.6415 18.3859 17.5674
440145...................................................... 13.6577 17.0608 18.3948 16.1716
440147...................................................... 22.0069 21.4304 26.1464 23.0399
440148...................................................... 17.6438 19.2435 19.4598 18.7842
440149...................................................... 17.1496 16.6923 18.4281 17.4374
440150...................................................... 13.0775 20.1411 20.3006 17.2935
440151...................................................... 15.4250 17.4248 18.3928 17.0781
440152...................................................... 17.8399 21.0287 22.7664 20.2196
440153...................................................... 16.0954 16.7769 16.5716 16.4916
440156...................................................... 19.6117 29.5557 21.7577 23.1575
440157...................................................... 11.3982 16.9265 18.4249 15.5384
440159...................................................... 17.6237 17.7158 20.9371 18.4872
440161...................................................... 20.7643 21.8013 22.8816 21.7855
440162...................................................... 14.4121 14.7637 15.5534 14.8623
440166...................................................... 18.1413 19.6684 19.2159 18.9985
440168...................................................... 15.9513 18.6535 19.1509 17.9995
440173...................................................... 18.4683 18.6402 19.1812 18.7699
440174...................................................... 17.0080 17.3294 18.0865 17.4583
440175...................................................... 17.6107 20.0802 18.5186 18.7356
440176...................................................... 18.7529 18.0294 19.2208 18.6470
440180...................................................... 17.3412 19.7773 20.2184 19.1376
440181...................................................... 11.8471 16.4878 17.7709 15.0662
440182...................................................... 20.3202 17.7487 19.7094 19.1341
440183...................................................... 19.4374 22.7067 21.3465 21.1277
440184...................................................... 18.0603 17.2037 16.8880 17.4646
440185...................................................... 18.7286 19.3870 21.2188 19.7784
440186...................................................... 18.5312 19.3948 19.7983 19.2465
440187...................................................... 16.2530 18.9713 17.5872 17.6013
440189...................................................... 16.1906 * 18.5252 17.4309
440192...................................................... 19.9669 19.0839 19.1705 19.3968
440193...................................................... 18.3952 19.0811 18.6999 18.7380
440194...................................................... 20.3343 19.8682 22.4562 20.9277
440197...................................................... 23.1080 21.9618 21.8503 22.2548
440200...................................................... 16.0619 17.9575 19.8078 18.0280
440203...................................................... 16.6132 18.3400 16.2861 17.0710
440206...................................................... 15.5462 16.4429 * 16.0270
440209...................................................... 14.7466 * * 14.7466
440210...................................................... 12.3292 11.0218 11.9815 11.7402
440211...................................................... * 14.8972 * 14.8972
440212...................................................... * 17.0685 * 17.0685
440213...................................................... * 19.5760 * 19.5760
440214...................................................... * * 28.0285 28.0285
440215...................................................... * * 22.2928 22.2928
450002...................................................... 19.9195 21.3749 21.4836 20.9147
450004...................................................... 15.2751 16.6723 16.7850 16.2360
450005...................................................... 15.5888 18.3600 16.6396 16.8103
450007...................................................... 15.7536 16.9681 19.1910 17.3218
450008...................................................... 15.7458 17.0832 17.6582 16.7901
450010...................................................... 16.0790 16.5001 17.6677 17.0234
450011...................................................... 18.0137 17.1942 20.8102 18.6782
450014...................................................... 18.2173 17.9495 17.5815 17.9004
450015...................................................... 18.4400 18.9895 21.6773 19.6131
450016...................................................... 17.3054 18.4463 18.3456 18.0337
450018...................................................... 20.4133 21.4788 23.2293 21.6061
450020...................................................... 16.9661 17.8415 19.1153 18.0122
450021...................................................... 22.6910 23.0843 23.3630 23.0474
450023...................................................... 16.6408 16.0831 17.6360 16.7896
450024...................................................... 16.5604 17.3518 18.5985 17.4846
[[Page 40023]]
450025...................................................... 16.4396 17.0004 * 16.7280
450028...................................................... 18.4287 18.8764 19.1658 18.8489
450029...................................................... 17.6909 17.4716 17.7425 17.6360
450031...................................................... 20.8992 22.2222 29.6945 23.8280
450032...................................................... 15.2404 17.3317 14.6530 15.6504
450033...................................................... 20.8634 19.7437 21.0222 20.5422
450034...................................................... 18.9068 19.6721 18.8823 19.1560
450035...................................................... 16.8132 20.0951 20.3599 19.0234
450037...................................................... 18.6549 19.5411 19.9140 19.3829
450039...................................................... 22.0811 19.8143 19.7176 20.5536
450040...................................................... 17.5179 16.8534 19.6370 18.0669
450042...................................................... 17.5906 19.8921 18.8357 18.7392
450044...................................................... 21.0399 24.7961 21.0909 22.1921
450046...................................................... 17.0917 18.6536 17.3631 17.6586
450047...................................................... 13.9022 13.4486 16.9028 14.6102
450050...................................................... 13.0037 14.7669 17.7209 15.0293
450051...................................................... 20.0763 21.0236 21.1008 20.7301
450052...................................................... 13.5278 13.8881 15.5890 14.3570
450053...................................................... 17.3139 17.0467 17.2781 17.2160
450054...................................................... 21.9835 22.8960 15.9388 20.5562
450055...................................................... 14.8119 15.0433 15.8526 15.2415
450056...................................................... 20.0008 21.8436 21.8605 21.2529
450058...................................................... 16.9832 18.0967 18.6172 17.9075
450059...................................................... 14.2072 15.2168 19.8240 16.2886
450063...................................................... 13.8126 14.3815 12.7211 13.5914
450064...................................................... 16.4165 17.4093 19.7682 17.8341
450065...................................................... 19.6087 21.4934 23.3797 21.3723
450068...................................................... 22.6924 22.8998 23.3495 22.9910
450072...................................................... 17.3794 19.0111 18.0307 18.1442
450073...................................................... 16.6168 17.1002 16.5942 16.7690
450078...................................................... 13.4875 11.7265 13.2820 12.8188
450079...................................................... 19.4899 21.0518 20.6483 20.4464
450080...................................................... 16.3147 17.4553 18.6212 17.4805
450081...................................................... 16.1653 16.3448 17.5737 16.7023
450082...................................................... 13.2952 16.1585 16.8677 15.5279
450083...................................................... 20.1830 21.5884 23.3754 21.7298
450085...................................................... 14.2167 18.3602 20.0085 17.2728
450087...................................................... 21.4764 22.0273 21.9320 21.8111
450090...................................................... 13.9101 15.0939 15.5796 14.8590
450092...................................................... 15.7316 16.8260 17.9520 16.8805
450094...................................................... 19.4249 21.3158 23.2863 21.3961
450096...................................................... 16.6300 17.8813 18.6802 17.7158
450097...................................................... 18.2740 19.5723 19.7187 19.2252
450098...................................................... 15.4796 20.5754 19.0454 18.3431
450099...................................................... 22.8834 19.2258 20.4181 20.6312
450101...................................................... 16.9628 17.1330 17.7928 17.2860
450102...................................................... 18.8465 18.6707 19.8793 19.1269
450104...................................................... 15.9781 16.6744 17.0821 16.5911
450107...................................................... 20.7359 25.1986 24.1094 23.2223
450108...................................................... 16.1451 15.6324 15.2797 15.6413
450109...................................................... 12.7654 13.8127 10.5973 12.1326
450110...................................................... 21.4421 19.5821 * 20.4354
450111...................................................... 19.2749 19.6350 21.4908 20.1993
450112...................................................... 14.7610 16.0441 18.1026 16.3114
450113...................................................... 18.5356 20.9777 20.8306 19.9901
450118...................................................... 15.8317 17.9053 * 16.9195
450119...................................................... 18.3166 20.2853 20.2030 19.6520
450121...................................................... 18.2278 20.4641 21.9198 20.1751
450123...................................................... 19.1912 15.7618 14.1755 16.0237
450124...................................................... 21.0925 22.7480 22.5208 22.1327
450126...................................................... 17.4512 21.7233 21.4789 19.9557
450128...................................................... 15.8881 18.2184 18.1446 17.4552
450130...................................................... 17.8722 20.4156 18.9211 19.0565
[[Page 40024]]
450131...................................................... 17.6163 19.2589 17.4168 18.0711
450132...................................................... 18.0745 18.1713 21.8089 19.3784
450133...................................................... 19.9259 23.6366 26.0763 23.0339
450135...................................................... 20.8065 21.0306 20.4068 20.7284
450137...................................................... 23.9555 22.4590 23.4346 23.2829
450140...................................................... 18.0743 20.2280 17.3370 18.5682
450143...................................................... 14.4623 14.5270 15.0871 14.7298
450144...................................................... 16.3037 18.1121 17.4309 17.3356
450145...................................................... 14.8441 15.6078 16.1895 15.5356
450146...................................................... 14.2041 17.8572 15.5030 15.8115
450147...................................................... 18.0664 18.9363 19.0477 18.6958
450148...................................................... 22.0269 18.6758 20.4923 20.3406
450149...................................................... 24.0005 19.7521 21.7219 21.7182
450150...................................................... 15.2061 16.3719 17.8612 16.4235
450151...................................................... 14.8373 15.2906 16.4209 15.5098
450152...................................................... 17.3780 18.0061 17.7265 17.7015
450153...................................................... 19.9447 19.4419 18.6514 19.3436
450154...................................................... 13.1810 13.8731 13.9119 13.6623
450155...................................................... 23.7678 11.5841 13.3456 14.7760
450157...................................................... 14.6623 15.6371 15.3083 15.2158
450160...................................................... 8.7503 16.6533 10.6852 11.1452
450162...................................................... 22.1981 20.9560 21.9218 21.6852
450163...................................................... 16.9811 17.5403 17.8028 17.4591
450164...................................................... 20.0368 16.9741 17.7180 18.0843
450165...................................................... 15.1561 13.9218 17.3283 15.3582
450166...................................................... 10.2801 11.4772 11.0541 10.9545
450169...................................................... 15.8793 13.1990 * 14.1674
450170...................................................... 14.8131 14.2997 14.3234 14.4821
450176...................................................... 16.3031 16.9674 17.2576 16.8653
450177...................................................... 14.7280 14.9241 15.2419 14.9812
450178...................................................... 16.7550 17.8508 16.0280 16.8828
450181...................................................... 14.0192 15.5622 18.6936 16.1716
450184...................................................... 19.9674 21.1263 20.0821 20.3949
450185...................................................... 13.0632 14.0714 11.5228 12.7662
450187...................................................... 17.5702 16.6945 18.5053 17.5863
450188...................................................... 13.7757 14.3938 15.1954 14.4624
450191...................................................... 18.8023 20.1222 20.9512 19.9757
450192...................................................... 19.3352 20.3795 21.2497 20.3207
450193...................................................... 22.7325 23.1963 23.1639 23.0345
450194...................................................... 19.1466 20.5187 20.7745 20.1569
450196...................................................... 16.4929 17.1955 17.8993 17.1933
450200...................................................... 17.3756 18.7387 19.2228 18.4203
450201...................................................... 17.0548 16.9908 17.1463 17.0668
450203...................................................... 18.6552 20.6712 19.3978 19.6025
450209...................................................... 18.6566 19.0811 20.0140 19.2218
450210...................................................... 14.2317 13.9758 16.3470 14.7958
450211...................................................... 17.1433 17.9857 18.8114 17.9863
450213...................................................... 18.4472 17.7631 19.0651 18.4304
450214...................................................... 17.2465 19.0475 20.5070 18.8579
450217...................................................... 11.6893 12.8457 12.7647 12.4509
450219...................................................... 15.4207 15.3976 17.6884 16.1962
450221...................................................... 16.9935 16.3700 15.2120 16.1091
450222...................................................... 18.4542 20.3129 19.8967 19.5439
450224...................................................... 22.8300 24.9046 20.1579 22.3861
450229...................................................... 16.4116 16.4503 16.7853 16.5551
450231...................................................... 17.7045 19.1564 19.1746 18.9853
450234...................................................... 13.3012 16.1945 16.3003 15.4055
450235...................................................... 13.4177 15.2332 16.3115 15.0648
450236...................................................... 15.6774 16.6703 16.4957 16.3054
450237...................................................... 17.3984 20.7930 19.0325 19.0438
450239...................................................... 13.6376 17.1308 17.8401 16.0311
450241...................................................... 14.8674 12.5675 16.4240 14.4148
450243...................................................... 12.3626 11.9099 13.6416 12.6485
[[Page 40025]]
450246...................................................... 17.9702 16.5478 16.7959 17.0548
450249...................................................... 11.6279 12.0302 11.7658 11.8055
450250...................................................... 14.9133 10.2844 13.6787 12.3052
450253...................................................... 15.3542 12.2402 13.2177 13.4392
450258...................................................... 13.2334 16.0466 16.7337 15.4196
450259...................................................... 17.8488 * * 17.8488
450264...................................................... 13.8879 13.8929 14.5956 14.1447
450269...................................................... 14.9334 12.3594 12.7717 13.2360
450270...................................................... 12.7018 12.8381 14.4792 13.2703
450271...................................................... 15.4998 16.6319 16.7831 16.3572
450272...................................................... 17.9514 19.9331 18.4344 18.7713
450276...................................................... 12.7053 13.1155 14.0745 13.3159
450278...................................................... 13.7894 14.8291 15.2950 14.5985
450280...................................................... 19.4926 22.2984 22.2936 21.3667
450283...................................................... 13.8916 14.5664 15.1950 14.5306
450286...................................................... 12.1212 * * 12.1212
450288...................................................... 15.9878 16.2502 18.8935 16.9454
450289...................................................... 18.3478 20.3104 20.3460 19.6703
450292...................................................... 19.5050 16.9693 20.5335 18.8754
450293...................................................... 14.4281 16.0132 16.2721 15.6074
450296...................................................... 20.6628 21.6000 22.3430 21.5410
450299...................................................... 17.9678 21.5672 * 19.7778
450303...................................................... 12.6720 12.4582 12.8996 12.6812
450306...................................................... 13.3165 13.8216 14.2047 13.8205
450307...................................................... 16.6779 16.4622 17.0691 16.7424
450309...................................................... 16.2055 13.1480 13.3771 14.0877
450315...................................................... 20.8043 22.8140 21.4684 21.6913
450320...................................................... 19.6331 20.0946 20.6596 20.1159
450321...................................................... 13.3932 13.1752 14.7344 13.7774
450322...................................................... 12.4570 22.7667 29.1884 20.6852
450324...................................................... 17.8697 17.7886 19.1692 18.2493
450327...................................................... 16.0935 11.7511 13.3639 13.4001
450330...................................................... 18.4163 18.9425 19.8066 19.0827
450334...................................................... 12.2721 12.8051 13.8392 12.9835
450337...................................................... 17.4208 17.1073 25.5708 18.8965
450340...................................................... 15.8519 17.6914 * 16.7663
450341...................................................... 19.1828 18.9429 * 19.0666
450346...................................................... 17.1038 17.5367 18.9475 17.8083
450347...................................................... 17.6908 17.1099 19.3475 18.0306
450348...................................................... 12.9414 13.9535 13.3585 13.4272
450351...................................................... 15.9772 18.4116 19.3159 17.9591
450352...................................................... 17.8528 18.7480 20.1871 18.9532
450353...................................................... 15.0020 17.7539 16.0003 16.2513
450355...................................................... 14.3182 11.9473 11.8933 12.5966
450358...................................................... 21.2812 22.3235 23.0206 22.2174
450362...................................................... 15.3536 15.8847 18.1983 16.4730
450369...................................................... 15.1854 15.2233 15.3122 15.2420
450370...................................................... 15.4368 12.6061 16.1369 14.6391
450371...................................................... 11.8996 24.6339 16.0236 16.3341
450372...................................................... 19.8589 20.0924 22.0746 20.6261
450373...................................................... 17.5998 17.4183 17.9554 17.6614
450374...................................................... 12.8264 13.6099 15.1750 13.8338
450378...................................................... 23.1598 23.5789 23.4599 23.4221
450379...................................................... 20.2756 22.7632 22.8756 21.9542
450381...................................................... 15.6215 16.4166 16.7112 16.2538
450388...................................................... 17.5561 19.2499 19.7408 18.8527
450389...................................................... 18.1478 18.1797 18.8448 18.4036
450393...................................................... 18.7387 20.2784 22.4992 20.3300
450395...................................................... 16.6754 18.3768 18.0024 17.6923
450399...................................................... 16.3066 15.7845 15.3491 15.8113
450400...................................................... 14.0761 19.5379 18.6668 17.2665
450403...................................................... 21.3691 20.1989 22.8430 21.4973
450411...................................................... 14.0463 14.4832 15.1121 14.5493
[[Page 40026]]
450417...................................................... 13.8517 13.4983 15.3591 14.2291
450418...................................................... 20.5847 21.9161 21.9690 21.5007
450419...................................................... 21.8196 20.6325 23.2551 21.9114
450422...................................................... 24.5309 26.4848 28.0257 26.2815
450423...................................................... 19.4352 22.7132 * 20.9607
450424...................................................... 17.5658 18.9741 18.7895 18.4852
450429...................................................... 11.3811 13.8723 * 12.4654
450431...................................................... 16.2696 19.6304 22.0361 19.0606
450438...................................................... 16.5461 19.5028 15.4553 17.0919
450446...................................................... 21.9685 13.0986 20.7592 18.0346
450447...................................................... 16.6124 18.0376 18.0377 17.5317
450451...................................................... 19.6424 18.8948 18.2988 18.9126
450457...................................................... 19.7689 24.7880 19.6569 21.1382
450460...................................................... 14.2156 15.1765 14.6523 14.6666
450462...................................................... 20.1347 22.6212 22.1144 21.6206
450464...................................................... 13.4714 13.2931 15.5908 14.0563
450465...................................................... 15.2203 15.5650 15.4731 15.4326
450467...................................................... 15.6034 10.6184 17.0004 13.7745
450469...................................................... 22.1012 19.6269 22.1930 21.2351
450473...................................................... 14.1895 19.9761 19.7148 17.9827
450475...................................................... 16.2489 16.3404 16.9269 16.5089
450484...................................................... 19.5869 16.8131 18.9825 18.4097
450488...................................................... 18.6813 19.3457 19.2173 19.0899
450489...................................................... 14.5747 9.9326 16.3584 13.1235
450497...................................................... 11.9242 15.0886 16.2997 14.3957
450498...................................................... 12.0249 13.8551 14.4713 13.5076
450508...................................................... 19.8722 18.8069 19.0991 19.2442
450514...................................................... 22.2791 21.3243 20.0144 21.2387
450517...................................................... 12.8702 27.8815 14.3191 16.6822
450518...................................................... 19.0112 19.8116 21.4873 20.0415
450523...................................................... 20.2589 20.0792 21.0393 20.4436
450530...................................................... 22.9101 22.8623 21.1634 22.2676
450534...................................................... 24.0835 19.9376 20.1520 21.2600
450535...................................................... 21.2659 19.6645 21.0513 20.6461
450537...................................................... 21.7432 20.8438 20.1161 20.8690
450538...................................................... 19.6864 * * 19.6864
450539...................................................... 14.2536 16.4921 18.7559 16.5056
450544...................................................... 19.3848 23.9283 23.6652 21.9211
450545...................................................... 16.9674 19.5558 20.2823 18.9428
450547...................................................... 13.8074 14.8248 18.1524 15.7208
450551...................................................... 13.9069 16.9439 16.6237 15.8128
450558...................................................... 20.0164 22.2574 20.7404 21.0120
450559...................................................... 13.4572 * * 13.4572
450561...................................................... 16.8162 * * 16.8162
450563...................................................... 30.3744 19.9218 22.0708 22.9095
450565...................................................... 16.4545 16.2652 17.3803 16.7063
450570...................................................... 17.7135 18.9532 19.0336 18.5591
450571...................................................... 16.9705 17.5598 18.2784 17.6264
450573...................................................... 15.6698 12.2502 17.3518 14.9746
450574...................................................... 14.2411 14.5965 14.6128 14.4845
450575...................................................... 19.0613 19.3925 22.5621 20.3955
450578...................................................... 16.8731 15.4783 18.0925 16.7620
450580...................................................... 15.3581 15.8321 16.7374 16.0231
450583...................................................... 15.5040 15.6580 14.4411 15.1895
450584...................................................... 13.3747 14.2321 14.6735 14.1004
450586...................................................... 12.8439 14.3773 13.8248 13.7154
450587...................................................... 17.1124 17.0230 18.0219 17.3661
450591...................................................... 17.9151 17.8981 17.7795 17.8608
450596...................................................... 14.8232 22.5420 21.6729 19.1117
450597...................................................... 16.1797 17.0776 17.6179 16.9806
450603...................................................... 12.7682 11.6442 23.5572 15.3844
450604...................................................... 15.4790 16.4535 17.6582 16.5641
450605...................................................... 20.1541 21.1400 19.4580 20.2362
[[Page 40027]]
450609...................................................... 10.7323 15.9753 17.0986 14.6244
450610...................................................... 16.7464 18.9924 21.5191 19.2633
450614...................................................... 13.8304 17.9853 16.5754 15.9153
450615...................................................... 14.7457 14.8562 15.2956 14.9778
450617...................................................... 19.5381 20.3387 20.8919 20.3006
450620...................................................... 13.7063 15.8380 16.0987 15.2421
450623...................................................... 21.8275 22.1950 23.1270 22.3514
450626...................................................... 19.7896 18.1673 18.4349 18.7617
450628...................................................... 16.8345 20.5611 18.6093 18.6475
450630...................................................... 19.1904 21.6876 20.9605 20.5728
450631...................................................... 17.5555 20.0417 21.6736 19.4992
450632...................................................... 12.7295 11.7587 13.9147 12.7814
450633...................................................... 20.7209 19.5183 19.4949 19.8926
450634...................................................... 20.2932 23.5333 22.9877 22.3295
450638...................................................... 19.6968 23.1437 22.1704 21.6228
450639...................................................... 20.3050 23.1936 21.6421 21.6608
450641...................................................... 13.5049 16.5125 15.7578 15.1652
450643...................................................... 17.4268 18.7054 16.8152 17.6481
450644...................................................... 20.7904 23.6587 22.7721 22.2903
450646...................................................... 19.9866 19.8274 19.1433 19.6406
450647...................................................... 22.4196 24.7981 24.2763 23.8588
450648...................................................... 14.7541 14.8488 15.0305 14.8793
450649...................................................... 15.8156 16.4496 16.6577 16.3245
450651...................................................... 20.7304 22.7664 22.7112 22.1063
450652...................................................... 16.6461 13.4389 17.2445 15.4912
450653...................................................... 19.2847 18.1834 19.2349 18.8580
450654...................................................... 13.8833 14.5258 14.5423 14.3223
450656...................................................... 18.7328 17.6723 18.2606 18.1968
450658...................................................... 15.1477 16.2657 17.2630 16.2787
450659...................................................... 20.5609 22.2550 23.0108 21.9106
450661...................................................... 20.2196 19.7160 18.9071 19.5857
450662...................................................... 18.6797 18.2284 19.3152 18.7697
450665...................................................... 15.4395 15.2015 16.1319 15.5906
450666...................................................... 19.3456 20.3248 20.2549 19.9584
450668...................................................... 18.7218 20.6965 21.0972 20.1590
450669...................................................... 22.2832 21.7632 21.6746 21.8862
450670...................................................... 18.2030 16.8893 20.2632 18.5133
450672...................................................... 21.2079 21.8559 21.4927 21.5115
450673...................................................... 13.8444 13.9620 13.7005 13.8283
450674...................................................... 20.6151 22.2796 22.2426 21.7353
450675...................................................... 23.2587 22.4961 21.4479 22.2858
450677...................................................... 18.7905 22.6839 20.6556 20.7200
450678...................................................... 20.7453 23.2617 24.1301 22.6596
450683...................................................... 21.1748 20.9143 22.8699 21.6172
450684...................................................... 22.8552 19.7005 21.9962 21.3850
450686...................................................... 15.0122 16.5661 16.4632 15.9861
450688...................................................... 20.8988 19.6250 20.1831 20.2348
450690...................................................... 22.4118 21.6578 22.4707 22.1725
450694...................................................... 18.4917 17.4758 18.1872 18.0283
450696...................................................... 17.5701 24.9636 * 21.1885
450697...................................................... 15.9259 18.8405 19.4949 18.0008
450698...................................................... 14.3983 14.6680 15.4750 14.8475
450700...................................................... 15.1153 14.6421 15.9050 15.2506
450702...................................................... 21.0157 20.8223 21.3739 21.0706
450703...................................................... 18.8029 * * 18.8029
450704...................................................... 21.6236 20.9821 20.7987 21.1724
450705...................................................... 22.3175 30.0116 22.1809 24.2035
450706...................................................... 21.3777 21.2072 22.0884 21.5769
450709...................................................... 19.7741 20.8889 22.1490 21.0078
450711...................................................... 18.2350 19.8126 19.8581 19.3268
450712...................................................... 16.8942 13.6240 15.9298 15.4007
450713...................................................... 23.6009 20.8065 22.6986 22.2836
450715...................................................... 19.7719 22.0413 22.5988 21.5504
[[Page 40028]]
450716...................................................... 19.9871 20.5544 20.9074 20.4812
450717...................................................... 19.4546 20.7192 20.6551 20.2618
450718...................................................... 19.0679 19.6886 22.1765 20.3069
450723...................................................... 19.7044 19.7563 20.8213 20.1083
450724...................................................... 20.0667 20.3235 20.3706 20.2569
450725...................................................... 19.5572 * * 19.5572
450727...................................................... 17.7508 13.5458 17.9172 16.1802
450728...................................................... 12.9277 17.5284 19.8879 16.6493
450730...................................................... 20.9129 22.0819 23.0054 22.0459
450733...................................................... 20.3718 20.7693 20.2199 20.4645
450735...................................................... 8.0014 13.8767 * 10.0108
450742...................................................... 20.7775 22.7655 21.8392 21.8145
450743...................................................... 15.9493 18.8937 19.6015 18.1561
450746...................................................... 20.7534 12.7904 30.2657 19.9075
450747...................................................... 17.3842 19.2585 20.3914 18.9599
450749...................................................... 12.9542 16.2130 19.1678 16.2656
450750...................................................... 14.7207 14.6914 13.8098 14.4310
450751...................................................... 22.2491 21.2198 19.9995 21.3756
450754...................................................... 14.8896 16.0860 16.7145 15.9455
450755...................................................... 14.7070 17.9904 19.8743 17.5601
450757...................................................... 13.9636 13.8675 14.9434 14.2422
450758...................................................... 18.6513 21.8669 19.0221 19.8347
450760...................................................... 18.0690 17.4852 19.2225 18.2582
450761...................................................... 11.1444 13.6152 15.7681 13.3382
450763...................................................... 17.5603 18.2123 18.6092 18.1083
450766...................................................... 21.8103 22.4348 23.3879 22.5926
450769...................................................... 13.6183 14.5858 18.4163 15.2554
450770...................................................... 16.8250 16.5458 19.0183 17.4436
450771...................................................... 21.5814 22.4542 21.8268 21.9636
450774...................................................... 16.5198 17.9964 16.2948 16.9482
450775...................................................... 19.9651 19.8897 21.3504 20.4169
450776...................................................... 10.1953 15.7750 14.1720 13.1591
450777...................................................... 19.5923 21.0682 19.0380 19.9747
450779...................................................... 22.9697 21.4546 21.6642 21.8768
450780...................................................... 15.2800 19.1498 19.0914 17.6291
450785...................................................... 18.5475 18.4976 * 18.5211
450788...................................................... 20.9806 19.1463 19.6469 19.7295
450794...................................................... 18.3981 18.2229 * 18.3485
450795...................................................... 14.1682 16.6494 22.5753 17.9737
450796...................................................... 17.4472 16.5362 19.2059 17.6627
450797...................................................... 18.5901 15.9188 16.4923 16.8594
450798...................................................... 9.2165 9.4634 * 9.3327
450801...................................................... 16.6095 17.5669 17.9548 17.3668
450802...................................................... 18.9018 19.9168 17.1435 18.5477
450803...................................................... 16.2047 18.3767 21.6653 19.3492
450804...................................................... 20.2223 19.4846 19.0893 19.5891
450807...................................................... 13.2256 11.3192 13.4306 12.5547
450808...................................................... 45.4728 16.9915 17.4917 21.1577
450809...................................................... 19.0266 20.0202 19.7899 19.6416
450811...................................................... 18.3847 19.0961 19.9168 19.1389
450812...................................................... 20.7383 * * 20.7383
450813...................................................... * 15.9166 14.5392 15.1549
450815...................................................... * * 21.2741 21.2741
450819...................................................... * * 16.5521 16.5521
450820...................................................... * * 26.8348 26.8348
450822...................................................... * * 22.8556 22.8556
460001...................................................... 20.6336 21.7996 22.2735 21.5846
460003...................................................... 20.5958 20.0452 22.6289 21.0329
460004...................................................... 20.8196 21.3744 21.7234 21.3231
460005...................................................... 17.5818 19.7069 22.5252 19.8732
460006...................................................... 19.6485 20.6252 21.0700 20.4918
460007...................................................... 20.5677 20.8026 21.1922 20.8840
460008...................................................... 21.0338 18.8661 19.1153 19.6864
[[Page 40029]]
460009...................................................... 21.1084 21.9016 22.5295 21.8515
460010...................................................... 21.2473 21.9830 22.4948 21.9354
460011...................................................... 16.7114 18.8660 19.7674 18.3702
460013...................................................... 20.3331 20.7326 20.1936 20.4306
460014...................................................... 19.5465 18.3865 18.5370 18.7488
460015...................................................... 20.0987 20.6593 21.0470 20.6197
460016...................................................... 18.0791 18.2408 21.9105 19.2998
460017...................................................... 26.0310 17.7103 18.9929 19.9984
460018...................................................... 16.8566 17.6235 17.0063 17.1606
460019...................................................... 17.3683 16.2671 17.8690 17.1417
460020...................................................... 17.0271 17.3467 17.2663 17.2239
460021...................................................... 20.2613 21.0470 21.5174 20.9913
460022...................................................... 18.2100 20.1534 21.3614 19.7210
460023...................................................... 21.3321 22.3535 22.9265 22.2381
460024...................................................... 13.0279 * * 13.0279
460025...................................................... 12.5083 19.4247 17.3494 16.5301
460026...................................................... 17.3431 19.9241 20.2576 19.0202
460027...................................................... 20.8331 21.8868 22.2955 21.6637
460029...................................................... 17.2501 20.5154 20.8366 19.2190
460030...................................................... 17.2196 17.6071 17.1383 17.3160
460032...................................................... 19.5474 21.1006 21.4832 20.7171
460033...................................................... 15.7233 19.5372 19.2664 18.1972
460035...................................................... 14.2802 16.0021 16.1685 15.4874
460036...................................................... 22.3788 23.5893 23.4573 23.1384
460037...................................................... 18.7665 18.6850 17.7399 18.3920
460039...................................................... 24.4781 24.9134 24.4808 24.6217
460041...................................................... 21.6926 21.0623 20.2035 20.9715
460042...................................................... 17.8455 18.8814 19.5662 18.7473
460043...................................................... 23.8970 24.4779 23.2819 23.8380
460044...................................................... 20.6897 21.4696 21.8485 21.3516
460046...................................................... 17.1085 18.2224 * 17.6742
460047...................................................... 21.3843 23.0433 22.7524 22.4777
460049...................................................... 18.8206 19.6483 20.8283 19.8892
460050...................................................... 26.2485 * * 26.2485
460051...................................................... 20.9797 19.4761 22.1758 20.8643
460052...................................................... * * 19.8961 19.8961
470001...................................................... 19.6108 20.2299 21.3817 20.4021
470003...................................................... 22.5949 23.6949 22.0563 22.7712
470004...................................................... 18.0952 16.8842 18.1879 17.7051
470005...................................................... 21.5151 21.9191 23.1808 22.1962
470006...................................................... 18.3898 17.8699 20.2829 18.8123
470008...................................................... 19.4136 19.6069 20.1969 19.7378
470010...................................................... 19.4652 20.2961 21.0616 20.2790
470011...................................................... 21.2014 21.7675 22.2415 21.7386
470012...................................................... 18.5162 18.5339 18.9444 18.6579
470015...................................................... 19.2552 19.5366 20.2125 19.6399
470018...................................................... 20.4161 21.5426 21.2406 21.0610
470020...................................................... 18.9884 20.6643 21.5688 20.4558
470023...................................................... 20.6391 20.4511 21.7139 20.9439
470024...................................................... 20.4087 20.8510 21.9807 21.0777
490001...................................................... 24.7604 21.9755 20.0570 22.0422
490002...................................................... 12.9871 15.2287 15.7365 14.6222
490003...................................................... 18.0034 19.1040 20.3237 19.1299
490004...................................................... 18.7731 19.2126 19.7074 19.2382
490005...................................................... 16.9087 20.5517 21.3318 19.6257
490006...................................................... 15.2276 15.9537 12.3253 14.5928
490007...................................................... 18.4330 18.7740 19.8938 19.0586
490009...................................................... 22.9513 23.9344 23.7659 23.5499
490010...................................................... 18.5780 21.7424 * 19.9381
490011...................................................... 18.7508 18.6071 19.8042 19.0282
490012...................................................... 13.7788 15.9973 15.2965 15.0022
490013...................................................... 16.9324 17.3318 18.2396 17.5085
490014...................................................... 24.5557 25.8315 23.5266 24.6242
[[Page 40030]]
490015...................................................... 19.3608 19.6363 20.0667 19.6821
490017...................................................... 17.3152 18.4361 19.3854 18.3964
490018...................................................... 17.9433 18.3435 18.5508 18.2858
490019...................................................... 17.5309 19.6178 21.0124 19.4215
490020...................................................... 17.6655 18.5691 19.3424 18.5533
490021...................................................... 19.4490 19.3945 20.0496 19.6794
490022...................................................... 20.7223 21.2183 22.3380 21.4351
490023...................................................... 18.9587 20.6694 21.5683 20.4224
490024...................................................... 16.8904 17.7221 18.4314 17.8400
490027...................................................... 14.4234 16.2761 16.7556 15.8360
490030...................................................... 10.5029 9.1789 8.6446 9.5559
490031...................................................... 15.8213 14.9539 16.0003 15.5875
490032...................................................... 21.5592 22.4262 21.4037 21.7854
490033...................................................... 18.3265 21.1723 19.2908 19.5511
490037...................................................... 15.9704 16.3759 17.0113 16.4399
490038...................................................... 15.7099 21.0218 17.6324 17.9048
490040...................................................... 22.5237 22.7061 24.1266 23.1321
490041...................................................... 16.5542 18.3589 18.7987 17.8901
490042...................................................... 15.2717 16.4666 17.0972 16.2668
490043...................................................... 20.6775 22.1574 22.1068 21.7221
490044...................................................... 17.6282 18.3137 19.7842 18.6148
490045...................................................... 19.6325 20.5468 20.5558 20.2593
490046...................................................... 18.6112 18.4825 19.9102 19.0232
490047...................................................... 17.1631 25.0438 18.7614 19.8637
490048...................................................... 17.8907 18.4361 19.5417 18.6005
490050...................................................... 22.7129 23.0729 23.3668 23.0530
490052...................................................... 16.9363 16.8600 16.4787 16.7609
490053...................................................... 15.6883 15.6996 16.8410 16.1062
490054...................................................... 15.5516 15.4734 19.5780 16.7024
490057...................................................... 19.0668 19.9210 20.3160 19.7770
490059...................................................... 20.3744 20.8662 21.4801 20.8999
490060...................................................... 19.2006 17.6308 18.5917 18.4363
490063...................................................... 28.2527 28.6536 26.1930 27.6341
490066...................................................... 16.5024 20.6972 19.8352 18.9146
490067...................................................... 17.1922 17.0195 17.8487 17.3549
490069...................................................... 15.6986 17.3297 20.7582 17.8379
490071...................................................... 19.4701 21.8879 23.3511 21.4480
490073...................................................... 26.1420 20.7960 26.0957 24.1488
490074...................................................... 19.3417 * * 19.3417
490075...................................................... 19.1906 18.6983 19.2156 19.0267
490077...................................................... 19.7866 21.3670 22.6504 21.2469
490079...................................................... 16.4379 17.0815 17.7016 17.0749
490083...................................................... 16.6406 * * 16.6406
490084...................................................... 16.3846 16.7834 18.0555 17.0646
490085...................................................... 16.3979 17.4584 17.6158 17.1539
490088...................................................... 15.5982 16.4362 17.9141 16.6068
490089...................................................... 15.8618 17.7692 18.2290 17.2642
490090...................................................... 16.2785 17.0199 17.5799 16.9734
490091...................................................... 19.9949 20.8734 25.0272 21.8088
490092...................................................... 15.6893 16.9533 16.4360 16.3528
490093...................................................... 16.4767 17.3711 17.8275 17.2502
490094...................................................... 16.7880 18.9204 22.3033 19.3562
490095...................................................... 18.2495 * * 18.2495
490097...................................................... 15.8586 15.5780 16.9518 16.0789
490098...................................................... 14.6971 15.1403 16.0488 15.2544
490099...................................................... 16.8667 17.9665 18.3985 17.7293
490100...................................................... 17.2189 22.5010 * 19.8823
490101...................................................... 25.0907 24.7616 23.5553 24.4275
490104...................................................... 28.4910 25.6889 40.2529 29.2590
490105...................................................... 18.2461 18.5765 21.4428 19.2491
490106...................................................... 16.9117 17.6596 26.3821 18.9838
490107...................................................... 22.4054 23.5240 22.9283 22.9660
490108...................................................... 19.7478 20.2112 24.1232 21.0559
[[Page 40031]]
490109...................................................... 21.1589 23.6620 25.9475 23.4402
490110...................................................... 15.8408 16.5131 18.1561 16.8181
490111...................................................... 17.3453 17.1768 17.8510 17.4580
490112...................................................... 20.5239 21.4532 22.1162 21.3613
490113...................................................... 23.0840 23.2235 23.9043 23.4071
490114...................................................... 16.9083 17.3047 18.0359 17.4375
490115...................................................... 17.1023 16.5203 16.8537 16.8239
490116...................................................... 16.4436 16.6170 17.2040 16.7676
490117...................................................... 13.8429 14.0104 14.7944 14.2244
490118...................................................... 20.8707 21.4674 23.2022 21.8304
490119...................................................... 17.8686 17.9147 18.6046 18.1353
490120...................................................... 19.9810 19.3707 20.5777 19.9742
490122...................................................... 23.9695 23.8801 23.8198 23.8925
490123...................................................... 16.8505 17.7461 19.3056 18.0001
490124...................................................... 19.3616 22.0884 21.3818 20.8857
490126...................................................... 18.2276 18.6844 20.4294 19.0254
490127...................................................... 14.4815 16.0516 16.5993 15.6547
490129...................................................... 27.4701 22.5885 28.6868 25.1130
490130...................................................... 16.2779 16.4322 17.6943 16.7915
490132...................................................... 17.0204 18.6570 18.4671 18.0649
500001...................................................... 21.3476 22.1896 24.4829 22.6367
500002...................................................... 21.0375 21.6332 19.8476 20.7811
500003...................................................... 24.3055 24.2814 24.4333 24.3392
500005...................................................... 23.4808 22.3955 24.3870 23.3703
500007...................................................... 22.4269 26.0599 21.9911 23.4148
500008...................................................... 24.1930 25.3064 26.1737 25.2130
500011...................................................... 25.1836 24.0162 24.6554 24.5938
500012...................................................... 22.2815 20.7032 24.2799 22.3541
500014...................................................... 23.9276 24.3419 24.0990 24.1249
500015...................................................... 23.2435 23.9297 24.9923 24.0554
500016...................................................... 23.9034 24.3938 24.9439 24.4287
500019...................................................... 22.3668 22.4213 23.2054 22.6470
500021...................................................... 24.4622 25.9198 27.6490 25.9957
500023...................................................... 27.1892 26.6535 27.1025 26.9568
500024...................................................... 24.0453 23.7472 26.6452 24.7736
500025...................................................... 23.9557 26.4810 24.4825 24.9695
500026...................................................... 23.3491 23.8005 26.9884 24.7238
500027...................................................... 25.0529 22.2158 25.1125 24.0804
500028...................................................... 18.8588 19.2675 18.9556 19.0337
500029...................................................... 16.8083 17.9237 18.5042 17.7373
500030...................................................... 24.1321 24.9039 26.3828 25.1714
500031...................................................... 23.3659 29.2707 23.6099 25.1784
500033...................................................... 21.3906 22.3527 22.5462 22.1428
500036...................................................... 21.8950 22.1096 23.6333 22.5254
500037...................................................... 19.6803 20.7139 21.4059 20.6062
500039...................................................... 23.3211 23.8918 24.0007 23.7403
500041...................................................... 24.8556 23.9608 25.4376 24.7549
500042...................................................... 22.1286 22.9125 * 22.5386
500043...................................................... 20.2509 20.9459 22.0466 21.0230
500044...................................................... 23.1128 23.3364 24.2212 23.5535
500045...................................................... 22.0982 20.8881 24.0526 22.2906
500048...................................................... 19.3029 22.1906 20.3207 20.5960
500049...................................................... 22.9534 24.0489 24.5997 23.8657
500050...................................................... 20.9445 22.0065 22.6563 21.9092
500051...................................................... 24.4769 24.8203 25.9447 25.1087
500053...................................................... 22.0515 23.9397 22.8399 22.9429
500054...................................................... 22.9024 22.8829 23.8089 23.1889
500055...................................................... 22.8769 23.7446 23.8622 23.5097
500057...................................................... 18.0424 18.2737 19.0479 18.4516
500058...................................................... 23.3984 24.7882 24.1106 24.0962
500059...................................................... 22.5412 23.3506 26.6270 24.1016
500060...................................................... 23.5360 25.0233 28.3655 25.4628
500061...................................................... 20.3957 21.7013 20.8624 20.9851
[[Page 40032]]
500062...................................................... 19.4607 18.6329 19.0557 19.0333
500064...................................................... 24.5283 25.5748 26.7000 25.6273
500065...................................................... 21.4254 21.9308 23.5671 22.3106
500068...................................................... 18.6960 19.6574 19.2638 19.2003
500069...................................................... 20.6262 21.3592 21.4542 21.1522
500071...................................................... 19.3810 19.1906 19.1428 19.2439
500072...................................................... 24.4599 25.3928 25.2001 25.0228
500073...................................................... 21.4303 21.2469 21.7698 21.4835
500074...................................................... 18.6506 18.9679 19.5981 19.0849
500077...................................................... 23.2056 22.8536 23.9410 23.3357
500079...................................................... 22.9809 24.2036 23.1041 23.4248
500080...................................................... 13.8000 15.6630 18.3883 15.5897
500084...................................................... 22.2169 23.4032 24.4044 23.3798
500085...................................................... 28.6121 21.4403 20.4517 22.7948
500086...................................................... 22.3132 23.3288 22.8829 22.8469
500088...................................................... 23.6988 23.2701 25.2478 24.0737
500089...................................................... 17.9399 18.7080 19.7166 18.7736
500090...................................................... 16.3297 16.1576 20.4429 17.2562
500092...................................................... 17.2881 16.7913 19.2028 17.7527
500094...................................................... 18.1080 18.5835 15.7866 17.6577
500096...................................................... 20.9580 21.0151 23.3564 21.7716
500097...................................................... 20.8010 19.7706 20.8774 20.4568
500098...................................................... 12.9935 16.3511 15.2040 14.9340
500101...................................................... 19.4498 19.7337 15.8000 18.3994
500102...................................................... 20.3321 20.9389 21.8963 21.0615
500104...................................................... 22.5849 22.8154 24.9389 23.3843
500106...................................................... 18.7087 18.6041 19.1465 18.7914
500107...................................................... 17.2987 18.1201 17.9489 17.8064
500108...................................................... 27.2126 26.2939 28.6229 27.3944
500110...................................................... 21.4053 21.4553 22.9775 21.9505
500118...................................................... 22.9245 23.8397 24.8034 23.8697
500119...................................................... 21.5704 22.4373 22.1192 22.0436
500122...................................................... 21.9135 22.4268 23.5264 22.6230
500123...................................................... 19.5855 20.3181 19.6646 19.8819
500124...................................................... 24.1473 23.2836 23.7742 23.7287
500125...................................................... 16.6272 15.1112 14.7910 15.5165
500129...................................................... 23.5952 26.1575 25.4685 25.1115
500132...................................................... 19.3567 15.6717 23.1822 19.3937
500134...................................................... 20.9570 17.7457 17.2430 18.5700
500139...................................................... 20.8816 22.2297 22.3053 21.8379
500141...................................................... 22.9358 23.8838 29.9695 25.5485
500143...................................................... 17.6031 18.0343 18.2570 17.9797
500146...................................................... 17.8558 21.6003 * 19.6218
510001...................................................... 17.8282 19.1492 20.0429 18.9855
510002...................................................... 17.3409 20.1527 17.6392 18.3009
510005...................................................... 14.4330 14.2503 13.8621 14.1872
510006...................................................... 17.8821 18.7313 19.9609 18.8717
510007...................................................... 20.2483 21.2729 21.6761 21.0848
510008...................................................... 17.3653 18.3296 19.0513 18.2388
510012...................................................... 16.5037 15.8390 15.6089 15.9887
510013...................................................... 16.6194 17.8527 19.5798 17.9628
510015...................................................... 14.7904 14.9039 16.7311 15.5193
510016...................................................... 12.0276 * * 12.0276
510018...................................................... 16.4757 18.5269 18.5358 17.8403
510020...................................................... 12.6472 13.1837 14.1211 13.3435
510022...................................................... 19.8375 20.1763 21.5770 20.5146
510023...................................................... 15.9417 16.0129 16.7777 16.2444
510024...................................................... 18.7982 19.0941 18.7461 18.8794
510026...................................................... 13.4586 13.6888 13.7952 13.6491
510027...................................................... 17.5759 17.2900 18.5945 17.8135
510028...................................................... 20.7306 20.0628 19.9208 20.2198
510029...................................................... 17.0519 17.7124 18.4668 17.7625
510030...................................................... 18.3137 17.4198 17.7603 17.8189
[[Page 40033]]
510031...................................................... 18.4887 28.6673 18.6341 21.0020
510033...................................................... 18.8061 18.4082 18.4718 18.5670
510035...................................................... 18.6471 16.5007 18.3164 17.7425
510036...................................................... 13.1995 13.4559 13.8786 13.5021
510038...................................................... 14.3433 15.8132 15.5576 15.2710
510039...................................................... 16.0555 16.9398 17.1461 16.7060
510043...................................................... 14.2872 14.0662 13.1308 13.8129
510046...................................................... 17.7320 17.3821 18.5896 17.9120
510047...................................................... 19.1202 19.8963 20.8101 19.9042
510048...................................................... 20.3734 21.0407 17.1647 19.5052
510050...................................................... 16.5681 16.9136 18.4036 17.3154
510053...................................................... 15.5856 16.1036 17.5798 16.4010
510055...................................................... 22.8376 23.7248 24.2133 23.6043
510058...................................................... 17.9786 18.4156 18.4501 18.2860
510059...................................................... 16.7732 16.5854 16.1044 16.5068
510060...................................................... 15.6581 17.5594 * 16.5969
510061...................................................... 14.2227 13.8204 14.1968 14.0767
510062...................................................... 17.6276 19.3881 18.1588 18.4173
510065...................................................... 14.5882 * * 14.5882
510066...................................................... 12.7164 12.2943 * 12.5091
510067...................................................... 18.1079 16.7161 17.3067 17.3634
510068...................................................... 16.2864 18.7938 23.0452 19.1223
510070...................................................... 16.3616 18.5146 18.7091 17.9505
510071...................................................... 16.2390 17.2148 18.0278 17.1797
510072...................................................... 17.6579 15.6262 15.9257 16.4174
510077...................................................... 16.4111 18.0668 18.2947 17.6316
510080...................................................... 14.7966 17.4485 16.3453 16.1690
510081...................................................... 13.0020 13.6359 11.9701 12.8648
510082...................................................... 13.6905 17.4538 13.5946 14.7307
510084...................................................... 12.4820 17.2395 13.5339 14.4076
510085...................................................... 18.6367 17.5624 18.6227 18.2581
510086...................................................... 13.7937 13.4763 14.2241 13.8304
510088...................................................... * * 14.8854 14.8854
520002...................................................... 18.3521 19.7447 19.6755 19.2773
520003...................................................... 16.4334 17.1248 18.7956 17.5028
520004...................................................... 18.1744 19.6512 20.4591 19.4206
520006...................................................... 20.4446 21.5313 21.4884 21.1400
520007...................................................... 13.1087 16.2001 18.4629 16.0134
520008...................................................... 22.8024 22.8024 24.9395 23.5372
520009...................................................... 18.5094 18.6002 21.4638 19.4842
520010...................................................... 20.3447 22.7703 22.3311 21.8215
520011...................................................... 20.3797 20.7410 21.5223 20.8830
520013...................................................... 21.6289 20.3965 20.5944 20.8585
520014...................................................... 16.3989 17.1646 18.0841 17.1764
520015...................................................... 18.3185 18.6078 19.7672 18.9031
520016...................................................... 13.2889 17.3018 18.4320 16.1862
520017...................................................... 19.3179 19.6008 19.4780 19.4685
520018...................................................... 18.6441 21.1941 21.5279 20.5280
520019...................................................... 18.3143 19.5440 20.9164 19.5698
520021...................................................... 20.0355 21.3471 21.9531 21.1390
520024...................................................... 14.6107 14.0175 14.4750 14.3609
520025...................................................... 18.1086 18.2430 20.3838 18.8661
520026...................................................... 19.8131 21.5453 20.8546 20.7335
520027...................................................... 18.9085 19.9324 21.5868 20.1744
520028...................................................... 19.1370 21.2852 22.5941 20.9020
520029...................................................... 16.7520 19.5750 21.4197 19.2161
520030...................................................... 20.0043 20.5039 21.6311 20.7089
520031...................................................... 18.7066 20.4814 20.9875 19.9520
520032...................................................... 17.9007 19.5697 21.1069 19.5434
520033...................................................... 18.8906 19.2954 20.2520 19.4725
520034...................................................... 16.6858 17.1282 20.4307 18.0336
520035...................................................... 17.0997 18.9452 18.7135 18.2608
520037...................................................... 20.0516 20.6686 21.6017 20.7624
[[Page 40034]]
520038...................................................... 17.7074 19.6294 20.6130 19.3169
520039...................................................... 19.5990 20.7641 23.3687 21.1069
520040...................................................... 20.7420 20.4677 21.2023 20.8002
520041...................................................... 15.3666 17.1959 18.4117 16.9517
520042...................................................... 17.6577 18.5843 19.5466 18.6338
520044...................................................... 17.7932 18.4014 19.1877 18.4535
520045...................................................... 19.6736 20.5917 21.2427 20.5162
520047...................................................... 17.8702 18.3048 20.3487 18.7633
520048...................................................... 19.1712 20.6583 19.8926 19.9142
520049...................................................... 19.5727 20.3559 20.1667 20.0444
520051...................................................... 19.7416 21.6497 24.0460 21.7205
520053...................................................... 16.4887 17.3945 18.0851 17.3336
520054...................................................... 15.9873 15.1747 16.8363 15.9586
520057...................................................... 18.3186 19.0872 19.8492 19.0812
520058...................................................... 18.1264 19.7283 21.2500 19.7133
520059...................................................... 19.8530 20.9913 21.5796 20.8254
520060...................................................... 17.1675 17.9258 18.8232 17.9582
520062...................................................... 17.8000 19.1482 19.7038 18.8681
520063...................................................... 20.7744 19.6136 20.5262 20.3055
520064...................................................... 21.4586 22.7423 22.0917 22.0917
520066...................................................... 22.4419 22.8837 24.0087 23.0580
520068...................................................... 18.0798 18.9943 19.6855 18.9053
520069...................................................... 17.9133 20.2934 20.1770 19.3716
520070...................................................... 17.8192 18.5938 19.4261 18.6155
520071...................................................... 18.7861 18.7304 19.9866 19.1576
520074...................................................... 18.6923 20.4601 20.9007 20.0036
520075...................................................... 19.0891 19.8457 20.7301 19.8876
520076...................................................... 16.5072 17.6088 19.5878 17.8567
520077...................................................... 15.5427 17.7830 18.7119 17.3266
520078...................................................... 20.5559 21.3380 21.7545 21.2404
520082...................................................... 16.7417 17.7405 * 17.1848
520083...................................................... 22.5715 23.8849 23.5787 23.3411
520084...................................................... 18.9475 20.8427 23.5446 21.0737
520087...................................................... 19.3942 20.3624 20.7821 20.1850
520088...................................................... 20.1529 20.6312 21.8931 20.8632
520089...................................................... 20.6110 21.5456 22.1055 21.4053
520090...................................................... 18.0026 18.9343 20.3645 19.1272
520091...................................................... 20.0693 20.9927 20.9440 20.6686
520092...................................................... 17.5577 17.6500 18.6248 17.9402
520094...................................................... 19.7791 20.3611 20.6179 20.2438
520095...................................................... 18.5066 20.3269 18.6425 19.1370
520096...................................................... 19.2980 19.7757 20.6668 19.9365
520097...................................................... 19.6470 20.2354 20.8016 20.2268
520098...................................................... 20.0289 22.3348 23.4707 21.9054
520100...................................................... 18.3788 18.3832 19.4788 18.7419
520101...................................................... 17.8453 19.5186 19.9875 19.1542
520102...................................................... 19.8354 20.1898 21.0138 20.3351
520103...................................................... 21.2324 19.4809 20.1092 20.2137
520107...................................................... 20.5441 20.3747 21.7907 20.8828
520109...................................................... 18.6322 19.1303 19.7609 19.1753
520110...................................................... 20.0319 20.4494 21.0055 20.5065
520111...................................................... 17.2388 17.7834 17.7673 17.6163
520112...................................................... 18.1827 19.1797 18.9577 18.7858
520113...................................................... 20.5925 21.1485 21.8852 21.2341
520114...................................................... 17.3799 16.6616 17.8476 17.2735
520115...................................................... 17.3755 18.2980 19.2248 18.2555
520116...................................................... 18.5698 19.8509 20.6922 19.7165
520117...................................................... 17.4242 18.5414 18.3963 18.1365
520118...................................................... 12.4422 14.2326 14.8626 13.8369
520120...................................................... 15.6205 18.7437 * 17.3887
520121...................................................... 17.5851 19.7305 20.8492 19.5992
520122...................................................... 16.7552 16.2436 16.9335 16.6326
520123...................................................... 17.4135 17.3980 17.7986 17.5610
[[Page 40035]]
520124...................................................... 16.3902 17.2619 17.9205 17.1864
520130...................................................... 15.1639 15.6845 16.6873 15.8395
520131...................................................... 18.8043 18.7295 20.2591 19.2549
520132...................................................... 17.2759 15.6379 18.1630 16.9564
520134...................................................... 17.6094 18.0953 18.8150 18.1846
520135...................................................... 14.4748 15.8246 17.3476 15.9083
520136...................................................... 19.9935 19.8480 20.9050 20.2727
520138...................................................... 20.8922 21.2260 22.5599 21.5577
520139...................................................... 21.2797 20.9988 21.4042 21.2251
520140...................................................... 21.4175 21.5207 22.3671 21.7731
520141...................................................... 16.9543 * * 16.9543
520142...................................................... 17.7003 20.5858 21.9432 19.9586
520144...................................................... 16.6231 18.5701 19.9120 18.4107
520145...................................................... 17.2356 18.2654 18.7958 18.1015
520146...................................................... 15.7318 17.9585 18.2370 17.3448
520148...................................................... 16.9293 17.2421 19.1502 17.8057
520149...................................................... 13.3032 14.1901 12.8928 13.4360
520151...................................................... 18.0771 17.3267 18.7070 18.0230
520152...................................................... 21.3333 19.5858 22.5980 21.0747
520153...................................................... 15.4467 15.9753 17.0863 16.1441
520154...................................................... 17.9229 18.5403 19.5994 18.6875
520156...................................................... 19.8396 21.3377 20.9638 20.7243
520157...................................................... 17.2784 17.1974 19.6008 18.0185
520159...................................................... 18.7423 18.6760 17.7649 18.3871
520160...................................................... 18.8444 19.4173 20.5154 19.5953
520161...................................................... 18.5742 19.4905 20.1102 19.4069
520170...................................................... 22.5033 21.5233 21.9857 21.9871
520171...................................................... 15.7316 17.4560 18.0785 17.1053
520173...................................................... 20.1410 21.3016 20.9209 20.7812
520177...................................................... 21.7609 22.7221 24.0139 22.8278
520178...................................................... 17.0411 18.6936 20.9010 18.7748
520188...................................................... * 13.9135 * 13.9135
530002...................................................... 17.5888 19.3273 21.0560 19.3920
530003...................................................... 15.7813 16.2139 15.9523 15.9820
530004...................................................... 16.1862 15.0497 13.3788 14.7758
530005...................................................... 15.1487 13.3529 15.3255 14.5529
530006...................................................... 19.3403 18.5894 19.1305 19.0082
530007...................................................... 18.0601 18.5161 17.7897 18.1450
530008...................................................... 22.9625 18.8349 19.0113 20.0471
530009...................................................... 19.4478 22.5009 21.7795 21.2113
530010...................................................... 18.9317 21.6092 13.9536 17.6719
530011...................................................... 17.4412 18.7354 19.4606 18.5542
530012...................................................... 19.4829 18.9923 21.1854 19.8564
530014...................................................... 17.3158 18.0869 18.4900 17.9675
530015...................................................... 22.6465 22.4568 23.4040 22.8118
530016...................................................... 17.7084 18.1562 19.3205 18.4153
530017...................................................... 13.7131 16.3478 17.7736 15.9421
530018...................................................... 17.8699 18.3783 19.5986 18.6254
530019...................................................... 16.7630 18.5430 20.1097 18.3351
530022...................................................... 17.8781 18.5002 19.6136 18.7082
530023...................................................... 20.7527 20.1948 20.0677 20.3449
530025...................................................... 20.3200 21.2598 22.0300 21.1974
530026...................................................... 18.9175 17.0118 19.8969 18.4992
530027...................................................... 29.7722 18.1664 25.5067 22.9705
530029...................................................... 17.7993 16.5092 19.3361 17.7626
530031...................................................... 13.3775 18.3322 20.1734 17.2600
530032...................................................... 20.2143 21.0361 20.0132 20.4281
----------------------------------------------------------------------------------------------------------------
*Asterisk denotes wage data not available for the provider that year.
**The 3-year average hourly wage is weighted by salaries and hours.
Federal Register / Vol. 66, No. 148 / Wednesday, August 1, 2001 /
Rules and Regulations
[[Page 40036]]
Table 3A.--FY 2002 and 3-Year* Average Hourly Wage for Urban Areas
[*Based on the sum of the salaries and hours computed for Federal fiscal
years 2000, 2001, and 2002]
------------------------------------------------------------------------
FY 2002 3-Year
Average Average
Urban Area Hourly Hourly
Wage Wage
------------------------------------------------------------------------
Abilene, TX....................................... 17.7691 17.6806
Aguadilla, PR..................................... 10.4485 9.2769
Akron, OH......................................... 22.0323 21.5752
Albany, GA........................................ 23.7363 22.4591
Albany-Schenectady-Troy, NY....................... 18.9628 18.7015
Albuquerque, NM................................... 21.7519 19.8583
Alexandria, LA.................................... 17.9113 17.4211
Allentown-Bethlehem-Easton, PA.................... 22.4824 21.9015
Altoona, PA....................................... 20.3592 20.1685
Amarillo, TX...................................... 19.4329 18.7074
Anchorage, AK..................................... 28.0436 27.7208
Ann Arbor, MI..................................... 24.7586 24.5264
Anniston, AL...................................... 18.4627 18.1432
Appleton-Oshkosh-Neenah, WI....................... 20.6158 19.7313
Arecibo, PR....................................... 10.3287 10.1229
Asheville, NC..................................... 20.5253 19.9864
Athens, GA........................................ 21.9578 21.2433
Atlanta, GA....................................... 22.4386 21.9090
Atlantic-Cape May, NJ............................. 25.1942 24.4875
Auburn-Opelika, AL................................ 18.3605 17.4403
Augusta-Aiken, GA-SC.............................. 22.2437 20.3470
Austin-San Marcos, TX............................. 21.4095 20.5134
Bakersfield, CA................................... 21.2373 20.8780
Baltimore, MD..................................... 21.9879 21.1182
Bangor, ME........................................ 21.4017 20.8620
Barnstable-Yarmouth, MA........................... 30.3987 29.5566
Baton Rouge, LA................................... 18.1796 18.6154
Beaumont-Port Arthur, TX.......................... 18.8344 18.7128
Bellingham, WA.................................... 26.3828 25.1714
Benton Harbor, MI................................. 19.8256 18.8187
Bergen-Passaic, NJ................................ 26.0785 25.7821
Billings, MT...................................... 20.8647 20.9984
Biloxi-Gulfport-Pascagoula, MS.................... 18.8292 17.8351
Binghamton, NY.................................... 18.8434 18.7661
Birmingham, AL.................................... 19.6498 19.0252
Bismarck, ND...................................... 17.8118 16.9730
Bloomington,IN.................................... 19.7257 18.9710
Bloomington-Normal, IL............................ 20.1643 19.6505
Boise City, ID.................................... 20.1899 19.6753
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.. 25.1952 24.5070
Boulder-Longmont, CO.............................. 21.8607 21.3813
Brazoria, TX...................................... 18.3149 18.3834
Bremerton, WA..................................... 24.0007 23.7403
Brownsville-Harlingen-San Benito, TX.............. 20.1061 19.5499
Bryan-College Station, TX......................... 20.8102 18.8209
Buffalo-Niagara Falls, NY......................... 21.1015 20.7620
Burlington, VT.................................... 22.0478 22.5833
Caguas, PR........................................ 10.4833 10.0219
Canton-Massillon, OH.............................. 19.9801 19.0700
Casper, WY........................................ 21.1855 19.8564
Cedar Rapids, IA.................................. 19.4080 19.1733
Champaign-Urbana, IL.............................. 20.7605 20.0368
Charleston-North Charleston, SC................... 20.5383 19.7662
Charleston, WV.................................... 20.6672 20.0125
Charlotte-Gastonia-Rock Hill, NC-SC............... 20.8279 20.4253
Charlottesville, VA............................... 23.5721 23.1481
Chattanooga, TN-GA................................ 20.9025 20.9736
Cheyenne, WY...................................... 18.4900 17.9675
Chicago, IL....................................... 24.6432 23.9647
Chico-Paradise, CA................................ 21.9881 21.8619
Cincinnati, OH-KY-IN.............................. 21.1338 20.5246
Clarksville-Hopkinsville, TN-KY................... 18.5997 17.8563
Cleveland-Lorain-Elyria, OH....................... 21.0982 20.8296
Colorado Springs, CO.............................. 21.7395 20.8047
Columbia, MO...................................... 19.3787 19.2453
Columbia, SC...................................... 21.1766 20.5897
Columbus, GA-AL................................... 18.8304 18.5114
Columbus, OH...................................... 21.3384 21.0849
Corpus Christi, TX................................ 18.6084 18.6824
Corvallis, OR..................................... 25.9828 24.7413
Cumberland, MD-WV................................. 18.5294 18.4566
Dallas, TX........................................ 22.1658 21.3656
Danville, VA...................................... 19.2156 19.0267
Davenport-Moline-Rock Island, IA-IL............... 19.2716 19.0340
Dayton-Springfield, OH............................ 20.5800 20.3849
Daytona Beach, FL................................. 20.0167 19.7043
Decatur, AL....................................... 19.5764 18.8565
Decatur, IL....................................... 17.8196 17.7118
Denver, CO........................................ 23.0415 22.2645
Des Moines, IA.................................... 19.5864 19.3257
Detroit, MI....................................... 23.3966 22.7762
Dothan, AL........................................ 17.7316 17.1772
Dover, DE......................................... 22.9706 21.5842
Dubuque, IA....................................... 19.0053 18.6795
Duluth-Superior, MN-WI............................ 22.9429 22.1011
Dutchess County, NY............................... 23.4959 22.7248
Eau Claire, WI.................................... 19.8536 19.3107
El Paso, TX....................................... 20.5588 19.9419
Elkhart-Goshen, IN................................ 21.5029 20.4359
Elmira, NY........................................ 18.7740 18.4812
Enid, OK.......................................... 18.6448 18.0515
Erie, PA.......................................... 19.4447 19.3682
Eugene-Springfield, OR............................ 25.5919 23.9337
Evansville, Henderson, IN-KY...................... 18.9936 18.1304
Fargo-Moorhead, ND-MN............................. 20.6740 19.3632
Fayetteville, NC.................................. 20.1393 19.0183
Fayetteville-Springdale-Rogers, AR................ 18.8407 17.4532
Flagstaff, AZ-UT.................................. 23.5500 22.9479
Flint, MI......................................... 24.3455 24.0039
Florence, AL...................................... 17.5023 16.9533
Florence, SC...................................... 19.4593 18.9517
Fort Collins-Loveland, CO......................... 22.4100 22.4773
Fort Lauderdale, FL............................... 22.9622 22.1804
Fort Myers-Cape Coral, FL......................... 20.9121 19.9782
Fort Pierce-Port St. Lucie, FL.................... 22.7860 21.5773
Fort Smith, AR-OK................................. 17.9648 17.3902
Fort Walton Beach, FL............................. 20.0841 19.8202
Fort Wayne, IN.................................... 20.5313 19.5510
Fort Worth-Arlington, TX.......................... 20.9570 20.8452
Fresno, CA........................................ 22.2730 22.0075
Gadsden, AL....................................... 19.6146 18.7634
Gainesville, FL................................... 21.1521 21.4897
Galveston-Texas City, TX.......................... 23.0087 21.6646
Gary, IN.......................................... 21.2620 20.5771
Glens Falls, NY................................... 18.5967 18.3428
Goldsboro, NC..................................... 19.4302 18.4900
Grand Forks, ND-MN................................ 20.2317 19.5346
Grand Junction, CO................................ 21.3486 20.1879
Grand Rapids-Muskegon-Holland, MI................. 22.4166 22.0645
Great Falls, MT................................... 19.7878 20.7979
Greeley, CO....................................... 21.1820 21.0411
Green Bay, WI..................................... 20.5432 19.9981
Greensboro-Winston-Salem-High Point, NC........... 21.2803 20.0780
Greenville, NC.................................... 20.7237 20.4264
Greenville-Spartanburg-Anderson, SC............... 20.5626 19.8772
Hagerstown, MD.................................... 18.6617 19.2372
Hamilton-Middletown, OH........................... 20.7196 19.8132
Harrisburg-Lebanon-Carlisle, PA................... 21.0273 20.8140
Hartford, CT...................................... 25.7288 25.0922
Hattiesburg, MS................................... 16.6793 16.3839
Hickory-Morganton-Lenoir, NC...................... 20.8978 19.9473
Honolulu, HI...................................... 25.7427 25.2694
Houma, LA......................................... 17.7919 17.3205
Houston, TX....................................... 21.4873 20.8626
Huntington-Ashland, WV-KY-OH...................... 21.4522 21.2133
Huntsville, AL.................................... 19.8172 19.3336
Indianapolis, IN.................................. 21.6359 21.2238
Iowa City, IA..................................... 21.9959 21.1012
Jackson, MI....................................... 20.6529 19.7626
Jackson, MS....................................... 18.9422 18.6455
Jackson, TN....................................... 20.1078 19.1864
Jacksonville, FL.................................. 20.5769 19.8750
Jacksonville, NC.................................. 17.0034 16.8680
Jamestown, NY..................................... 17.9583 17.1876
[[Page 40037]]
Janesville-Beloit, WI............................. 21.7281 20.9886
Jersey City, NJ................................... 24.9369 24.8965
Johnson City-Kingsport-Bristol, TN-VA............. 19.2235 18.6571
Johnstown, PA..................................... 19.4611 18.9954
Jonesboro, AR..................................... 18.7961 16.9923
Joplin, MO........................................ 19.4696 17.8013
Kalamazoo-Battlecreek, MI......................... 23.7355 22.5300
Kankakee, IL...................................... 22.0627 20.5487
Kansas City, KS-MO................................ 21.2753 20.5840
Kenosha, WI....................................... 21.3454 20.4490
Killeen-Temple, TX................................ 16.2682 19.9750
Knoxville, TN..................................... 19.8337 19.1504
Kokomo, IN........................................ 20.3602 19.9881
La Crosse, WI-MN.................................. 20.6365 19.8718
Lafayette, LA..................................... 19.0613 18.3994
Lafayette, IN..................................... 20.3481 19.3998
Lake Charles, LA.................................. 17.3224 16.7485
Lakeland-Winter Haven, FL......................... 20.2272 19.6704
Lancaster, PA..................................... 20.7395 20.1687
Lansing-East Lansing, MI.......................... 21.5357 21.4297
Laredo, TX........................................ 17.5103 17.6390
Las Cruces, NM.................................... 19.2336 18.7690
Las Vegas, NV-AZ.................................. 24.9460 24.1211
\1\ Lawrence, KS.................................. ......... 17.6233
Lawton, OK........................................ 19.3702 19.7127
Lewiston-Auburn, ME............................... 20.7185 19.7537
Lexington, KY..................................... 19.6123 18.9899
Lima, OH.......................................... 21.1268 20.0862
Lincoln, NE....................................... 22.6963 21.4133
Little Rock-North Little Rock, AR................. 19.9791 19.2054
Longview-Marshall, TX............................. 19.1225 19.0256
Los Angeles-Long Beach, CA........................ 26.6548 26.0962
Louisville, KY-IN................................. 21.2596 20.4841
Lubbock, TX....................................... 18.8491 18.6166
Lynchburg, VA..................................... 20.3083 19.4241
Macon, GA......................................... 19.9824 19.2057
Madison, WI....................................... 23.0613 21.9843
Mansfield, OH..................................... 19.4276 18.7455
Mayaguez, PR...................................... 10.8433 10.2295
McAllen-Edinburg-Mission, TX...................... 18.6914 18.1962
Medford-Ashland, OR............................... 23.0097 22.6022
Melbourne-Titusville-Palm Bay, FL................. 22.1149 20.9722
Memphis, TN-AR-MS................................. 20.0303 18.8000
Merced, CA........................................ 22.1904 21.6193
Miami, FL......................................... 22.1977 21.9246
Middlesex-Somerset-Hunterdon, NJ.................. 25.5879 24.3992
Milwaukee-Waukesha, WI............................ 22.2459 21.4514
Minneapolis-St. Paul, MN-WI....................... 24.3849 23.8437
Missoula, MT...................................... 20.8911 20.0992
Mobile, AL........................................ 18.0301 17.7727
Modesto, CA....................................... 24.1386 22.6578
Monmouth-Ocean, NJ................................ 24.2514 24.2156
Monroe, LA........................................ 18.2960 18.0030
Montgomery, AL.................................... 16.4170 16.4651
Muncie, IN........................................ 22.1725 22.9671
Myrtle Beach, SC.................................. 19.5681 18.6951
Naples, FL........................................ 21.6388 21.1816
Nashville, TN..................................... 21.7612 20.8163
Nassau-Suffolk, NY................................ 30.4363 30.1896
New Haven-Bridgeport-Stamford-Waterbury-Danbury, 27.3029 26.7357
CT...............................................
New London-Norwich, CT............................ 25.7135 26.0913
New Orleans, LA................................... 20.1579 19.8724
New York, NY...................................... 32.1854 31.5830
Newark, NJ........................................ 25.9290 25.4360
Newburgh, NY-PA................................... 24.7917 23.8549
Norfolk-Virginia Beach-Newport News, VA-NC........ 19.1397 18.4429
Oakland, CA....................................... 34.1768 32.8934
Ocala, FL......................................... 21.3185 20.6236
Odessa-Midland, TX................................ 22.5425 20.4491
Oklahoma City, OK................................. 19.3952 18.9190
Olympia, WA....................................... 25.3219 23.8950
Omaha, NE-IA...................................... 21.6670 21.5315
Orange County, CA................................. 24.8160 24.7793
Orlando, FL....................................... 21.5114 21.0699
Owensboro, KY..................................... 18.5923 17.8512
Panama City, FL................................... 20.2145 19.7652
Parkersburg-Marietta, WV-OH....................... 18.1448 17.9931
Pensacola, FL..................................... 18.6539 18.1053
Peoria-Pekin, IL.................................. 19.5717 18.6727
Philadelphia, PA-NJ............................... 24.4217 23.9480
Phoenix-Mesa, AZ.................................. 21.5030 20.8692
Pine Bluff, AR.................................... 17.6144 16.9553
Pittsburgh, PA.................................... 21.3283 20.9676
Pittsfield, MA.................................... 22.9287 22.3291
Pocatello, ID..................................... 21.0779 19.9570
Ponce, PR......................................... 11.6402 11.0089
Portland, ME...................................... 21.0314 20.7690
Portland-Vancouver, OR-WA......................... 24.7891 23.9331
Providence-Warwick, RI............................ 24.1057 23.4709
Provo-Orem, UT.................................... 21.9597 21.5577
Pueblo, CO........................................ 19.1954 19.0481
Punta Gorda, FL................................... 20.1130 20.3995
Racine, WI........................................ 20.8222 20.1696
Raleigh-Durham-Chapel Hill, NC.................... 21.9030 21.0278
Rapid City, SD.................................... 19.7860 18.9541
Reading, PA....................................... 21.3801 20.4191
Redding, CA....................................... 24.8864 24.7297
Reno, NV.......................................... 23.2497 22.9230
Richland-Kennewick-Pasco, WA...................... 24.4507 24.4034
Richmond-Petersburg, VA........................... 21.5917 20.8973
Riverside-San Bernardino, CA...................... 24.7903 24.3425
Roanoke, VA....................................... 18.6747 18.3527
Rochester, MN..................................... 25.5712 24.8162
Rochester, NY..................................... 20.8521 20.0838
Rockford, IL...................................... 20.5343 19.4475
Rocky Mount, NC................................... 20.3213 19.3679
Sacramento, CA.................................... 26.3945 26.1465
Saginaw-Bay City-Midland, MI...................... 21.3941 20.6362
St. Cloud, MN..................................... 21.9780 21.3047
\1\ St. Joseph, MO................................ ......... 19.3531
St. Louis, MO-IL.................................. 19.9244 19.5996
Salem, OR......................................... 22.3342 21.8859
Salinas, CA....................................... 32.7598 31.8419
Salt Lake City-Ogden, UT.......................... 22.0030 21.4144
San Angelo, TX.................................... 18.2784 17.4362
San Antonio, TX................................... 19.1516 18.4593
San Diego, CA..................................... 25.1307 25.3474
San Francisco, CA................................. 31.5450 30.6851
San Jose, CA...................................... 31.6633 30.0720
San Juan-Bayamon, PR.............................. 10.6229 10.2284
San Luis Obispo-Atascadero-Paso Robles, CA........ 24.5182 23.3041
Santa Barbara-Santa Maria-Lompoc, CA.............. 24.0983 23.3594
Santa Cruz-Watsonville, CA........................ 31.1654 30.4145
Santa Fe, NM...................................... 22.7435 22.5866
Santa Rosa, CA.................................... 29.0793 28.0256
Sarasota-Bradenton, FL............................ 22.5102 21.6154
Savannah, GA...................................... 20.6199 20.9278
Scranton-Wilkes Barre-Hazleton, PA................ 19.3713 18.4721
Seattle-Bellevue-Everett, WA...................... 25.3458 24.3975
Sharon, PA........................................ 17.6824 17.4957
Sheboygan, WI..................................... 18.7992 18.1442
Sherman-Denison, TX............................... 20.9115 19.8213
Shreveport-Bossier City, LA....................... 20.1898 19.4576
Sioux City, IA-NE................................. 19.5588 18.6963
Sioux Falls, SD................................... 20.3884 19.3356
South Bend, IN.................................... 22.2935 21.5894
Spokane, WA....................................... 23.7995 23.1813
Springfield, IL................................... 19.3559 18.8869
Springfield, MO................................... 19.1121 18.1563
Springfield, MA................................... 24.2745 23.3313
State College, PA................................. 20.3757 19.7984
Steubenville-Weirton, OH-WV....................... 19.2689 18.6797
Stockton-Lodi, CA................................. 24.1271 23.2304
Sumter, SC........................................ 17.3876 17.6174
Syracuse, NY...................................... 21.4641 20.7071
Tacoma, WA........................................ 25.9158 25.1530
Tallahassee, FL................................... 19.0232 18.5413
Tampa-St. Petersburg-Clearwater, FL............... 19.9114 19.5352
Terre Haute, IN................................... 19.0337 18.4440
Texarkana, AR-Texarkana, TX....................... 18.5780 17.9809
Toledo, OH........................................ 21.8824 21.3504
[[Page 40038]]
Topeka, KS........................................ 19.8816 19.8271
Trenton, NJ....................................... 23.2382 22.2118
Tucson, AZ........................................ 20.0050 19.2367
Tulsa, OK......................................... 19.8607 18.4406
Tuscaloosa, AL.................................... 18.2284 17.6510
Tyler, TX......................................... 21.5091 20.6026
Utica-Rome, NY.................................... 18.5820 18.2679
Vallejo-Fairfield-Napa, CA........................ 30.2552 28.8147
Ventura, CA....................................... 24.5276 24.2700
Victoria, TX...................................... 18.5790 18.0303
Vineland-Millville-Bridgeton, NJ.................. 23.2940 22.8113
Visalia-Tulare-Porterville, CA.................... 21.4790 21.4191
Waco, TX.......................................... 18.1355 17.7707
Washington, DC-MD-VA-WV........................... 24.4550 23.7621
Waterloo-Cedar Falls, IA.......................... 17.9383 18.0820
Wausau, WI........................................ 21.6311 20.7089
West Palm Beach-Boca Raton, FL.................... 21.8130 21.3673
Wheeling, OH-WV................................... 17.8134 16.9419
Wichita, KS....................................... 21.4307 20.6976
Wichita Falls, TX................................. 17.5498 16.8374
Williamsport, PA.................................. 19.2494 18.4198
Wilmington-Newark, DE-MD.......................... 24.2660 24.1627
Wilmington, NC.................................... 20.9901 20.6684
Yakima, WA........................................ 23.5754 22.3174
Yolo, CA.......................................... 21.6430 21.4983
York, PA.......................................... 21.0635 20.3115
Youngstown-Warren, OH............................. 21.3343 21.0926
Yuba City, CA..................................... 23.1110 23.0076
Yuma, AZ.......................................... 20.0535 20.5870
------------------------------------------------------------------------
\1\ The MSA is empty for FY 2002. The hospital(s) in the MSA received
rural status under Section 401 of the Balanced Budget Refinement Act
of 1999 (P.L. 106-113). The MSA is assigned the statewide rural wage
index (see Table 4B).
Table 3B.--FY 2002 and 3-Year* Average Hourly Wage for Rural Areas
[*Based on the sum of the salaries and hours computed for Federal Fiscal
years 2000, 2001, and 2002]
------------------------------------------------------------------------
FY 2002 3-Year
Average Average
Nonurban Area Hourly Hourly
Wage Wage
------------------------------------------------------------------------
Alabama........................................... 16.3730 16.1146
Alaska............................................ 26.4636 26.3425
Arizona........................................... 19.3673 18.5370
Arkansas.......................................... 16.7079 16.0831
California........................................ 21.5497 21.3758
Colorado.......................................... 19.6575 19.2833
Connecticut....................................... 26.9422 26.2306
Delaware.......................................... 21.3930 20.2349
Florida........................................... 19.6192 19.3651
Georgia........................................... 18.5057 17.9168
Hawaii............................................ 24.7906 23.8356
Idaho............................................. 19.4497 18.9015
Illinois.......................................... 17.9658 17.5928
Indiana........................................... 19.4553 18.6527
Iowa.............................................. 18.1754 17.4857
Kansas............................................ 17.4286 16.6018
Kentucky.......................................... 17.7644 17.3603
Louisiana......................................... 16.9467 16.4424
Maine............................................. 19.4557 18.9537
Maryland.......................................... 19.7644 18.9527
Massachusetts..................................... 25.5523 24.6681
Michigan.......................................... 20.0792 19.4470
Minnesota......................................... 20.1570 19.2809
Mississippi....................................... 16.7955 16.1984
Missouri.......................................... 17.6049 16.9330
Montana........................................... 19.3090 18.6615
Nebraska.......................................... 18.1647 17.6040
Nevada............................................ 21.6995 20.3605
New Hampshire..................................... 21.8156 21.4054
New Jersey \1\.................................... ......... .........
New Mexico........................................ 19.3566 18.5498
New York.......................................... 19.0675 18.6183
North Carolina.................................... 19.0403 18.3332
North Dakota...................................... 17.5784 16.8515
Ohio.............................................. 19.3379 18.8488
Oklahoma.......................................... 16.8803 16.1856
Oregon............................................ 22.3705 21.7851
Pennsylvania...................................... 19.2018 18.6374
Puerto Rico....................................... 10.7076 9.6394
Rhode Island \1\.................................. ......... .........
South Carolina.................................... 18.9889 18.2492
South Dakota...................................... 17.5369 16.6639
Tennessee......................................... 17.6873 16.9880
Texas............................................. 17.2050 16.4636
Utah.............................................. 20.1916 19.5942
Vermont........................................... 21.1189 20.4055
Virginia.......................................... 18.3851 17.6464
Washington........................................ 22.7769 22.5424
West Virginia..................................... 17.9971 17.6684
Wisconsin......................................... 20.2251 19.3721
Wyoming........................................... 19.5145 19.1625
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
------------------------------------------------------------------------
Wage
Urban Area (Constituent Counties) Index GAF
------------------------------------------------------------------------
0040 Abilene, TX................................... 0.7983 0.8570
Taylor, TX
0060 \2\ Aguadilla, PR............................. 0.4832 0.6077
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 0.9876 0.9915
Portage, OH
Summit, OH
0120 Albany, GA.................................... 1.0640 1.0434
Dougherty, GA
Lee, GA
0160 \2\ Albany-Schenectady-Troy, NY............... 0.8547 0.8981
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM............................... 0.9750 0.9828
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.8059 0.8626
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 1.0077 1.0053
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9126 0.9393
Blair, PA
0320 Amarillo, TX.................................. 0.8711 0.9098
Potter, TX
Randall, TX
0380 Anchorage, AK................................. 1.2696 1.1776
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1098 1.0739
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.8276 0.8785
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.9241 0.9474
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 \2\ Arecibo, PR............................... 0.4832 0.6077
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.9200 0.9445
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.9842 0.9892
Clarke, GA
Madison, GA
Oconee, GA
0520 \1\ Atlanta, GA............................... 1.0058 1.0040
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
[[Page 40039]]
Newton, GA
Paulding, GA
Pickens, GA
Rockdale, GA
Spalding, GA
Walton, GA
0560 Atlantic-Cape May, NJ......................... 1.1293 1.0868
Atlantic, NJ
Cape May, NJ
0580 Auburn-Opelika, AL............................ 0.8230 0.8751
Lee, AL
0600 Augusta-Aiken, GA-SC.......................... 0.9970 0.9979
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 \1\ Austin-San Marcos, TX..................... 0.9597 0.9722
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 \2\ Bakersfield, CA........................... 0.9659 0.9765
Kern, CA
0720 \1\ Baltimore, MD............................. 0.9856 0.9901
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.................................... 0.9593 0.9719
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.3626 1.2360
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8149 0.8692
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8442 0.8905
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1826 1.1217
Whatcom, WA
0870 \2\ Benton Harbor, MI......................... 0.9000 0.9304
Berrien, MI
0875 \1\ Bergen-Passaic, NJ........................ 1.1808 1.1205
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 0.9352 0.9552
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8440 0.8903
Hancock, MS
Harrison, MS
Jackson, MS
0960 \2\ Binghamton, NY............................ 0.8547 0.8981
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.8808 0.9168
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.7984 0.8571
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.8842 0.9192
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.9038 0.9331
McLean, IL
1080 Boise City, ID................................ 0.9050 0.9339
Ada, ID
Canyon, ID
1123 \1\ \2\ Boston-Worcester-Lawrence-Lowell- 1.1454 1.0974
Brockton, MA-NH (MA Hospitals).....................
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1123 \1\ Boston-Worcester-Lawrence-Lowell-Brockton, 1.1293 1.0868
MA-NH (NH Hospitals)...............................
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.......................... 0.9799 0.9862
Boulder, CO
1145 Brazoria, TX.................................. 0.8209 0.8736
Brazoria, TX
1150 Bremerton, WA................................. 1.0758 1.0513
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.9012 0.9312
Cameron, TX
1260 Bryan-College Station, TX..................... 0.9328 0.9535
Brazos, TX
1280 \1\ Buffalo-Niagara Falls, NY................. 0.9459 0.9626
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 0.9883 0.9920
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 \2\ Caguas, PR................................ 0.4832 0.6077
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH.......................... 0.8956 0.9273
Carroll, OH
Stark, OH
1350 Casper, WY.................................... 0.9496 0.9652
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.8699 0.9090
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.9306 0.9519
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.9206 0.9449
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9264 0.9490
Kanawha, WV
Putnam, WV
1520 \1\ Charlotte-Gastonia-Rock Hill, NC-SC....... 0.9407 0.9590
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 1.0566 1.0384
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.9369 0.9563
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 \2\ Cheyenne, WY.............................. 0.8747 0.9124
Laramie, WY
1600 \1\ Chicago, IL............................... 1.1046 1.0705
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
[[Page 40040]]
Will, IL
1620 Chico-Paradise, CA............................ 0.9856 0.9901
Butte, CA
1640 \1\ Cincinnati, OH-KY-IN...................... 0.9473 0.9636
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............... 0.8393 0.8869
Christian, KY
Montgomery, TN
1680 \1\ Cleveland-Lorain-Elyria, OH............... 0.9457 0.9625
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9744 0.9824
El Paso, CO
1740 Columbia, MO.................................. 0.8686 0.9080
Boone, MO
1760 Columbia, SC.................................. 0.9492 0.9649
Lexington, SC
Richland, SC
1800 Columbus, GA-AL...............................
Russell, AL 0.8440 0.8903
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 \1\ Columbus, OH.............................. 0.9565 0.9700
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.8341 0.8832
Nueces, TX
San Patricio, TX
1890 Corvallis, OR................................. 1.1646 1.1100
Benton, OR
1900 \2\ Cumberland, MD-WV (MD Hospitals).......... 0.8859 0.9204
Allegany, MD
Mineral, WV
1900 Cumberland, MD-WV (WV Hospital)............... 0.8306 0.8806
Allegany, MD
Mineral, WV
1920 \1\ Dallas, TX................................ 0.9936 0.9956
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.8613 0.9028
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8638 0.9046
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9225 0.9463
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL............................. 0.8972 0.9284
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.8775 0.9144
Lawrence, AL
Morgan, AL
2040 \2\ Decatur, IL............................... 0.8053 0.8622
Macon, IL
2080 \1\ Denver, CO................................ 1.0328 1.0223
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8779 0.9147
Dallas, IA
Polk, IA
Warren, IA
2160 \1\ Detroit, MI............................... 1.0487 1.0331
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.7988 0.8574
Dale, AL
Houston, AL
2190 Dover, DE..................................... 1.0296 1.0202
Kent, DE
2200 Dubuque, IA................................... 0.8519 0.8960
Dubuque, IA
2240 Duluth-Superior, MN-WI........................ 1.0284 1.0194
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY........................... 1.0532 1.0361
Dutchess, NY
2290 \2\ Eau Claire, WI............................ 0.9068 0.9352
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX................................... 0.9215 0.9456
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.9638 0.9751
Elkhart, IN
2335 \2\ Elmira, NY................................ 0.8547 0.8981
Chemung, NY
2340 Enid, OK...................................... 0.8357 0.8843
Garfield, OK
2360 Erie, PA...................................... 0.8716 0.9102
Erie, PA
2400 Eugene-Springfield, OR........................ 1.1471 1.0985
Lane, OR
2440 \2\ Evansville-Henderson, IN-KY (IN Hospitals) 0.8721 0.9105
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2440 Evansville-Henderson, IN-KY (KY Hospitals).... 0.8514 0.8957
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN......................... 0.9267 0.9492
Clay, MN
Cass, ND
2560 Fayetteville, NC.............................. 0.9027 0.9323
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.8445 0.8907
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 1.0556 1.0377
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.0913 1.0617
Genesee, MI
2650 Florence, AL.................................. 0.7889 0.8501
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8722 0.9106
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0045 1.0031
Larimer, CO
2680 \1\ Ft. Lauderdale, FL........................ 1.0784 1.0530
Broward, FL
2700 Fort Myers-Cape Coral, FL..................... 0.9374 0.9567
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 1.0214 1.0146
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.8053 0.8622
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL......................... 0.9002 0.9305
[[Page 40041]]
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.9203 0.9447
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 \1\ Fort Worth-Arlington, TX.................. 0.9394 0.9581
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 0.9984 0.9989
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8792 0.9156
Etowah, AL
2900 Gainesville, FL............................... 0.9481 0.9642
Alachua, FL
2920 Galveston-Texas City, TX...................... 1.0313 1.0213
Galveston, TX
2960 Gary, IN...................................... 0.9530 0.9676
Lake, IN
Porter, IN
2975 \2\ Glens Falls, NY........................... 0.8547 0.8981
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8709 0.9097
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.9119 0.9388
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.9774 0.9845
Mesa, CO
3000 \1\ Grand Rapids-Muskegon-Holland, MI......... 1.0048 1.0033
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 0.9195 0.9441
Cascade, MT
3060 Greeley, CO................................... 0.9495 0.9651
Weld, CO
3080 Green Bay, WI................................. 0.9357 0.9555
Brown, WI
3120 \1\ Greensboro-Winston-Salem-High Point, NC... 0.9539 0.9682
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9289 0.9507
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.9217 0.9457
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 \2\ Hagerstown, MD............................ 0.8859 0.9204
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.9287 0.9506
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 0.9425 0.9603
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 \1\ \2\ Hartford, CT.......................... 1.2077 1.1380
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 \2\ Hattiesburg, MS........................... 0.7528 0.8233
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.9367 0.9562
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1544 1.1033
Honolulu, HI
3350 Houma, LA..................................... 0.7975 0.8565
Lafourche, LA
Terrebonne, LA
3360 \1\ Houston, TX............................... 0.9631 0.9746
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9616 0.9735
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8883 0.9221
Limestone, AL
Madison, AL
3480 \1\ Indianapolis, IN.......................... 0.9698 0.9792
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9859 0.9903
Johnson, IA
3520 Jackson, MI................................... 0.9257 0.9485
Jackson, MI
3560 Jackson, MS................................... 0.8491 0.8940
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 0.9013 0.9313
Madison, TN
Chester, TN
3600 \1\ Jacksonville, FL.......................... 0.9223 0.9461
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 \2\ Jacksonville, NC.......................... 0.8535 0.8972
Onslow, NC
3610 \2\ Jamestown, NY............................. 0.8547 0.8981
Chautauqua, NY
3620 Janesville-Beloit, WI......................... 0.9739 0.9821
Rock, WI
3640 Jersey City, NJ............................... 1.1178 1.0792
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.8617 0.9031
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA................................. 0.8723 0.9107
Cambria, PA
Somerset, PA
3700 Jonesboro, AR................................. 0.8425 0.8893
Craighead, AR
3710 Joplin, MO.................................... 0.8727 0.9110
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 1.0639 1.0433
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.9889 0.9924
Kankakee, IL
3760 \1\ Kansas City, KS-MO........................ 0.9536 0.9680
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................................... 0.9568 0.9702
Kenosha, WI
3810 \2\ Killeen-Temple, TX........................ 0.7714 0.8372
[[Page 40042]]
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.8890 0.9226
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.9184 0.9434
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN.............................. 0.9250 0.9480
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8544 0.8978
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.9121 0.9389
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA.............................. 0.7765 0.8409
Calcasieu, LA
3980 Lakeland-Winter Haven, FL..................... 0.9067 0.9351
Polk, FL
4000 Lancaster, PA................................. 0.9296 0.9512
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 0.9653 0.9761
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.................................... 0.7849 0.8472
Webb, TX
4100 \2\ Las Cruces, NM............................ 0.8676 0.9073
Dona Ana, NM
4120 \1\ Las Vegas, NV-AZ.......................... 1.1182 1.0795
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.7812 0.8444
Douglas, KS
4200 Lawton, OK.................................... 0.8682 0.9078
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.9287 0.9506
Androscoggin, ME
4280 Lexington, KY................................. 0.8791 0.9155
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.9470 0.9634
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 1.0173 1.0118
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8955 0.9272
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX......................... 0.8571 0.8998
Gregg, TX
Harrison, TX
Upshur, TX
4480 \1\ Los Angeles-Long Beach, CA................ 1.1961 1.1305
Los Angeles, CA
4520 \1\ Louisville, KY-IN......................... 0.9529 0.9675
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8463 0.8920
Lubbock, TX
4640 Lynchburg, VA................................. 0.9103 0.9377
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.8971 0.9283
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 1.0367 1.0250
Dane, WI
4800 Mansfield, OH................................. 0.8726 0.9109
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4860 0.6101
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8378 0.8859
Hidalgo, TX
4890 Medford-Ashland, OR........................... 1.0314 1.0214
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.9913 0.9940
Brevard, Fl
4920 \1\ Memphis, TN-AR-MS......................... 0.8978 0.9288
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.................................... 0.9947 0.9964
Merced, CA
5000 \1\ Miami, FL................................. 0.9950 0.9966
Dade, FL
5015 \1\ Middlesex-Somerset-Hunterdon, NJ.......... 1.1469 1.0984
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 \1\ Milwaukee-Waukesha, WI.................... 0.9971 0.9980
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 \1\ Minneapolis-St. Paul, MN-WI............... 1.0930 1.0628
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.................................. 0.9364 0.9560
Missoula, MT
5160 Mobile, AL.................................... 0.8084 0.8645
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0820 1.0555
Stanislaus, CA
5190 \1\ Monmouth-Ocean, NJ........................ 1.1257 1.0845
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.................................... 0.8201 0.8730
Ouachita, LA
5240 \2\ Montgomery, AL............................ 0.7400 0.8137
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.................................... 0.9939 0.9958
Delaware, IN
5330 Myrtle Beach, SC.............................. 0.8771 0.9141
Horry, SC
5345 Naples, FL.................................... 0.9699 0.9793
Collier, FL
5360 \1\ Nashville, TN............................. 0.9754 0.9831
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 \1\ Nassau-Suffolk, NY........................ 1.3643 1.2370
Nassau, NY
[[Page 40043]]
Suffolk, NY
5483 \1\ New Haven-Bridgeport-Stamford-Waterbury-.. 1.2294 1.1519
Danbury, CT
Fairfield, CT
New Haven, CT
5523 \2\ New London-Norwich, CT.................... 1.2077 1.1380
New London, CT
5560 \1\ New Orleans, LA........................... 0.9036 0.9329
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 \1\ New York, NY.............................. 1.4427 1.2853
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 \1\ Newark, NJ................................ 1.1622 1.1084
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.1113 1.0749
Orange, NY
Pike, PA
5720 \1\ Norfolk-Virginia Beach-Newport News, VA-NC 0.8579 0.9004
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City VA
Williamsburg City, VA
York, VA
5775 \1\ Oakland, CA............................... 1.5319 1.3392
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.9556 0.9694
Marion, FL
5800 Odessa-Midland, TX............................ 1.0104 1.0071
Ector, TX
Midland, TX
5880 \1\ Oklahoma City, OK......................... 0.8694 0.9086
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA................................... 1.1350 1.0906
Thurston, WA
5920 Omaha, NE-IA.................................. 0.9712 0.9802
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 \1\ Orange County, CA......................... 1.1246 1.0837
Orange, CA
5960 \1\ Orlando, FL............................... 0.9642 0.9753
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY................................. 0.8334 0.8827
Daviess, KY
6015 Panama City, FL............................... 0.9061 0.9347
Bay, FL
6020 Parkersburg-Marietta, WV-OH (WV Hospitals).... 0.8133 0.8680
Washington, OH
Wood, WV
6020 \2\ Parkersburg-Marietta, WV-OH (OH Hospitals) 0.8668 0.9067
Washington, OH
Wood, WV
6080 \2\ Pensacola, FL............................. 0.8794 0.9158
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL.............................. 0.8773 0.9143
Peoria, IL
Tazewell, IL
Woodford, IL
6160 \1\Philadelphia, PA-NJ........................ 1.0947 1.0639
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 \1\ Phoenix-Mesa, AZ.......................... 0.9638 0.9751
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.7895 0.8506
Jefferson, AR
6280 \1\ Pittsburgh, PA............................ 0.9560 0.9697
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 \2\ Pittsfield, MA............................ 1.1454 1.0974
Berkshire, MA
6340 Pocatello, ID................................. 0.9448 0.9619
Bannock, ID
6360 Ponce, PR..................................... 0.5218 0.6405
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9427 0.9604
Cumberland, ME
Sagadahoc, ME
York, ME
6440 \1\ Portland-Vancouver, OR-WA................. 1.1150 1.0774
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 \1\ Providence-Warwick-Pawtucket, RI.......... 1.0805 1.0545
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 0.9843 0.9892
Utah, UT
6560 \2\ Pueblo, CO................................ 0.8811 0.9170
Pueblo, CO
6580 Punta Gorda, FL............................... 0.9015 0.9315
Charlotte, FL
6600 Racine, WI.................................... 0.9333 0.9538
Racine, WI
6640 \1\ Raleigh-Durham-Chapel Hill, NC............ 0.9818 0.9875
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8869 0.9211
Pennington, SD
6680 Reading, PA................................... 0.9583 0.9713
Berks, PA
6690 Redding, CA................................... 1.1155 1.0777
Shasta, CA
6720 Reno, NV...................................... 1.0421 1.0286
Washoe, NV
6740 Richland-Kennewick-Pasco, WA.................. 1.0960 1.0648
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 0.9678 0.9778
[[Page 40044]]
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780 \1\ Riverside-San Bernardino, CA.............. 1.1112 1.0749
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA................................... 0.8371 0.8854
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.1462 1.0979
Olmsted, MN
6840 \1\ Rochester, NY............................. 0.9347 0.9548
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.9204 0.9448
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.9109 0.9381
Edgecombe, NC
Nash, NC
6920 \1\ Sacramento, CA............................ 1.1831 1.1220
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9590 0.9717
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9919 0.9944
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.7899 0.8509
Andrew, MO
Buchanan, MO
7040 \1\ St. Louis, MO-IL.......................... 0.8931 0.9255
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080 \2\ Salem, OR................................. 1.0033 1.0023
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.4684 1.3009
Monterey, CA
71601Salt Lake City-Ogden, UT....................... 0.9863 0.9906
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.8193 0.8724
Tom Green, TX
7240 \1\ San Antonio, TX........................... 0.8584 0.9007
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 \1\ San Diego, CA............................. 1.1265 1.0850
San Diego, CA
7360 \1\ San Francisco, CA......................... 1.4140 1.2677
Marin, CA
San Francisco, CA
San Mateo, CA
7400 \1\ San Jose, CA.............................. 1.4193 1.2710
Santa Clara, CA
7440 \1\ \2\ San Juan-Bayamon, PR.................. 0.4832 0.6077
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.... 1.0990 1.0668
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.0802 1.0543
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.3970 1.2573
Santa Cruz, CA
7490 Santa Fe, NM.................................. 1.0194 1.0132
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA............................... 1.3034 1.1990
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 1.0090 1.0062
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 0.9243 0.9475
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA.......... 0.8683 0.9078
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 \1\ Seattle-Bellevue-Everett, WA.............. 1.1361 1.0913
Island, WA
King, WA
Snohomish, WA
7610 \2\ Sharon, PA................................ 0.8607 0.9024
Mercer, PA
7620 \2\ Sheboygan, WI............................. 0.9068 0.9352
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.9373 0.9566
Grayson, TX
7680 Shreveport-Bossier City, LA.................. 0.9050 0.9339
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8767 0.9138
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD............................... 0.9139 0.9402
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................ 0.9993 0.9995
St. Joseph, IN
7840 Spokane, WA................................... 1.0668 1.0453
Spokane, WA
7880 Springfield, IL............................... 0.8676 0.9073
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.8567 0.8995
Christian, MO
Greene, MO
Webster, MO
8003 \2\ Springfield, MA........................... 1.1454 1.0974
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.9133 0.9398
[[Page 40045]]
Centre, PA
8080 \2\ Steubenville-Weirton, OH-WV (OH Hospitals) 0.8668 0.9067
Jefferson, OH
Brooke, WV
Hancock, WV
8080 Steubenville-Weirton, OH-WV (WV Hospitals).... 0.8637 0.9045
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.0988 1.0666
San Joaquin, CA
8140 \2\ Sumter, SC................................ 0.8512 0.8955
Sumter, SC
8160 Syracuse, NY.................................. 0.9621 0.9739
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.................................... 1.1616 1.1080
Pierce, WA
8240 \2\ Tallahassee, FL........................... 0.8794 0.9158
Gadsden, FL
Leon, FL
8280 \1\ Tampa-St. Petersburg-Clearwater, FL....... 0.8925 0.9251
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 \2\ Terre Haute, IN........................... 0.8721 0.9105
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana,AR-Texarkana, TX.................... 0.8327 0.8822
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 0.9809 0.9869
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 0.8912 0.9242
Shawnee, KS
8480 Trenton, NJ.................................. 1.0416 1.0283
Mercer, NJ
8520 Tucson, AZ.................................... 0.8976 0.9287
Pima, AZ
8560 Tulsa, OK..................................... 0.8902 0.9234
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................ 0.8171 0.8708
Tuscaloosa, AL
8640 Tyler, TX..................................... 0.9641 0.9753
Smith, TX
8680 \2\ Utica-Rome, NY............................ 0.8547 0.8981
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.3562 1.2320
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.0994 1.0670
Ventura, CA
8750 Victoria, TX.................................. 0.8328 0.8822
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 1.0441 1.0300
Cumberland, NJ
8780 \2\ Visalia-Tulare-Porterville, CA............ 0.9659 0.9765
Tulare, CA
8800 Waco, TX...................................... 0.8150 0.8693
McLennan, TX
8840 \1\ Washington, DC-MD-VA-WV................... 1.0962 1.0649
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...................... 0.8677 0.9074
Black Hawk, IA
8940 Wausau, WI.................................... 0.9696 0.9791
Marathon, WI
8960 \1\ West Palm Beach-Boca Raton, FL............ 0.9777 0.9847
Palm Beach, FL
9000 \2\ Wheeling, WV-OH (WV Hospitals)............ 0.8067 0.8632
Belmont, OH
Marshall, WV
Ohio, WV
9000 \2\ Wheeling, WV-OH (OH Hospitals)............ 0.8668 0.9067
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.9606 0.9728
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.7946 0.8543
Archer, TX
Wichita, TX
9140 Williamsport, PA.............................. 0.8628 0.9039
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.0877 1.0593
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9409 0.9591
New Hanover, NC
Brunswick, NC
9260 Yakima, WA.................................... 1.0567 1.0385
Yakima, WA
9270 Yolo, CA...................................... 0.9701 0.9794
Yolo, CA
9280 York, PA...................................... 0.9441 0.9614
York, PA
9320 Youngstown-Warren, OH......................... 0.9563 0.9699
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0359 1.0244
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 0.8989 0.9296
Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area
\2\ Hospitals geographically located in the area are assigned the
statewide rural wage index for FY 2002.
Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban Area Index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7400 0.8137
Alaska.............................................. 1.1862 1.1240
Arizona............................................. 0.8681 0.9077
Arkansas............................................ 0.7489 0.8204
California.......................................... 0.9659 0.9765
Colorado............................................ 0.8811 0.9170
Connecticut......................................... 1.2077 1.1380
Delaware............................................ 0.9589 0.9717
Florida............................................. 0.8794 0.9158
Georgia............................................. 0.8295 0.8798
Hawaii.............................................. 1.1112 1.0749
Idaho............................................... 0.8718 0.9103
Illinois............................................ 0.8053 0.8622
Indiana............................................. 0.8721 0.9105
Iowa................................................ 0.8147 0.8691
Kansas.............................................. 0.7812 0.8444
Kentucky............................................ 0.7963 0.8556
Louisiana........................................... 0.7692 0.8355
Maine............................................... 0.8721 0.9105
Maryland............................................ 0.8859 0.9204
Massachusetts....................................... 1.1454 1.0974
Michigan............................................ 0.9000 0.9304
[[Page 40046]]
Minnesota........................................... 0.9035 0.9329
Mississippi......................................... 0.7528 0.8233
Missouri............................................ 0.7899 0.8509
Montana............................................. 0.8655 0.9058
Nebraska............................................ 0.8142 0.8687
Nevada.............................................. 0.9727 0.9812
New Hampshire....................................... 0.9779 0.9848
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.8676 0.9073
New York............................................ 0.8547 0.8981
North Carolina...................................... 0.8535 0.8972
North Dakota........................................ 0.7879 0.8494
Ohio................................................ 0.8668 0.9067
Oklahoma............................................ 0.7566 0.8261
Oregon.............................................. 1.0038 1.0026
Pennsylvania........................................ 0.8607 0.9024
Puerto Rico......................................... 0.4832 0.6077
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.8512 0.8955
South Dakota........................................ 0.7861 0.8481
Tennessee........................................... 0.7928 0.8530
Texas............................................... 0.7714 0.8372
Utah................................................ 0.9051 0.9340
Vermont............................................. 0.9608 0.9730
Virginia............................................ 0.8241 0.8759
Washington.......................................... 1.0209 1.0143
West Virginia....................................... 0.8067 0.8632
Wisconsin........................................... 0.9068 0.9352
Wyoming............................................. 0.8747 0.9124
------------------------------------------------------------------------
\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......................................... 0.7983 0.8570
Akron, OH........................................... 0.9876 0.9915
Albany, GA.......................................... 1.0640 1.0434
Albuquerque, NM..................................... 0.9750 0.9828
Alexandria, LA...................................... 0.8059 0.8626
Allentown-Bethlehem-Easton, PA...................... 1.0077 1.0053
Altoona, PA......................................... 0.9126 0.9393
Amarillo, TX........................................ 0.8502 0.8948
Anchorage, AK....................................... 1.2696 1.1776
Ann Arbor, MI....................................... 1.1098 1.0739
Anniston, AL........................................ 0.7841 0.8466
Asheville, NC....................................... 0.9200 0.9445
Athens, GA.......................................... 0.9706 0.9798
Atlanta, GA......................................... 1.0058 1.0040
Augusta-Aiken, GA-SC................................ 0.9970 0.9979
Austin-San Marcos, TX............................... 0.9597 0.9722
Barnstable-Yarmouth, MA............................. 1.3423 1.2234
Baton Rouge, LA..................................... 0.8149 0.8692
Bellingham, WA...................................... 1.1296 1.0870
Benton Harbor, MI................................... 0.9000 0.9304
Bergen-Passaic, NJ.................................. 1.1808 1.1205
Billings, MT........................................ 0.9352 0.9552
Biloxi-Gulfport-Pascagoula, MS...................... 0.8105 0.8660
Binghamton, NY...................................... 0.8607 0.9024
Birmingham, AL...................................... 0.8808 0.9168
Bismarck, ND........................................ 0.7984 0.8571
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1293 1.0868
Burlington, VT (VT Hospitals)....................... 0.9608 0.9730
Burlington, VT (NY Hospitals)....................... 0.9606 0.9728
Caguas, PR.......................................... 0.4832 0.6077
Casper, WY.......................................... 0.9346 0.9547
Champaign-Urbana, IL................................ 0.9140 0.9403
Charleston-North Charleston, SC..................... 0.9206 0.9449
Charleston, WV...................................... 0.8902 0.9234
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9407 0.9590
Chattanooga, TN-GA.................................. 0.9181 0.9432
Chicago, IL......................................... 1.0917 1.0619
Cincinnati, OH-KY-IN................................ 0.9473 0.9636
Clarksville-Hopkinsville, TN-KY..................... 0.8393 0.8869
Cleveland-Lorain-Elyria, OH......................... 0.9457 0.9625
Columbia, MO........................................ 0.8686 0.9080
Columbia, SC........................................ 0.9168 0.9422
Columbus, GA-AL..................................... 0.8440 0.8903
Columbus, OH........................................ 0.9565 0.9700
Corpus Christi, TX.................................. 0.8238 0.8757
Dallas, TX.......................................... 0.9936 0.9956
Davenport-Moline-Rock Island, IA-IL................. 0.8538 0.8974
Dayton-Springfield, OH.............................. 0.9225 0.9463
Denver, CO.......................................... 1.0328 1.0223
Des Moines, IA...................................... 0.8779 0.9147
Dothan, AL.......................................... 0.7988 0.8574
Dover, DE........................................... 1.0003 1.0002
Duluth-Superior, MN-WI.............................. 1.0284 1.0194
Eau Claire, WI...................................... 0.9068 0.9352
Elkhart-Goshen, IN.................................. 0.9517 0.9667
Erie, PA............................................ 0.8716 0.9102
Eugene-Springfield, OR.............................. 1.1006 1.0678
Fargo-Moorhead, ND-MN............................... 0.9166 0.9421
Fayetteville, NC.................................... 0.8869 0.9211
Flagstaff, AZ-UT.................................... 1.0105 1.0072
Flint, MI........................................... 1.0810 1.0548
Florence, AL........................................ 0.7889 0.8501
Florence, SC........................................ 0.8722 0.9106
Fort Collins-Loveland, CO........................... 1.0045 1.0031
Ft. Lauderdale, FL.................................. 1.0784 1.0530
Fort Pierce-Port St. Lucie, FL...................... 1.0114 1.0078
Fort Smith, AR-OK................................... 0.7857 0.8478
Fort Walton Beach, FL............................... 0.8828 0.9182
Fort Wayne, IN...................................... 0.9203 0.9447
Forth Worth-Arlington, TX........................... 0.9394 0.9581
Gadsden, AL......................................... 0.8386 0.8864
Gainesville, FL..................................... 0.9481 0.9642
Grand Forks, ND-MN.................................. 0.9119 0.9388
Grand Junction, CO.................................. 0.9774 0.9845
Grand Rapids-Muskegon-Holland, MI................... 0.9939 0.9958
Great Falls, MT..................................... 0.9195 0.9441
Greeley, CO......................................... 0.9495 0.9651
Green Bay, WI....................................... 0.9357 0.9555
Greensboro-Winston-Salem-High Point, NC............. 0.9395 0.9582
Greenville, NC...................................... 0.9289 0.9507
Greenville-Spartanburg-Anderson, SC................. 0.9217 0.9457
Harrisburg-Lebanon-Carlisle, PA..................... 0.9425 0.9603
Hartford, CT........................................ 1.1571 1.1051
Hattiesburg, MS..................................... 0.7528 0.8233
Hickory-Morganton-Lenoir, NC........................ 0.9367 0.9562
Honolulu, HI........................................ 1.1544 1.1033
Houston, TX......................................... 0.9631 0.9746
Huntington-Ashland, WV-KY-OH........................ 0.9238 0.9472
Huntsville, AL...................................... 0.8696 0.9088
Indianapolis, IN.................................... 0.9698 0.9792
Iowa City, IA....................................... 0.9708 0.9799
Jackson, MS......................................... 0.8491 0.8940
Jackson, TN......................................... 0.8843 0.9192
Jacksonville, FL.................................... 0.9223 0.9461
Johnson City-Kingsport-Bristol, TN-VA............... 0.8617 0.9031
Jonesboro, AR....................................... 0.8115 0.8667
Joplin, MO.......................................... 0.8528 0.8967
Kalamazoo-Battlecreek, MI........................... 1.0471 1.0320
Kansas City, KS-MO.................................. 0.9536 0.9680
Knoxville, TN....................................... 0.8890 0.9226
Kokomo, IN.......................................... 0.9184 0.9434
Lafayette, LA....................................... 0.8395 0.8871
Lansing-East Lansing, MI............................ 0.9653 0.9761
Las Vegas, NV-AZ.................................... 1.1182 1.0795
Lawton, OK.......................................... 0.8281 0.8788
Lexington, KY....................................... 0.8641 0.9048
Lima, OH............................................ 0.9470 0.9634
Lincoln, NE......................................... 0.9843 0.9892
Little Rock-North Little Rock, AR................... 0.8800 0.9162
Longview-Marshall, TX............................... 0.8571 0.8998
Los Angeles-Long Beach, CA.......................... 1.1961 1.1305
Louisville, KY-IN................................... 0.9416 0.9596
Lubbock, TX......................................... 0.8463 0.8920
Lynchburg, VA....................................... 0.8795 0.9158
Macon, GA........................................... 0.8971 0.9283
Madison, WI......................................... 1.0367 1.0250
Mansfield, OH....................................... 0.8726 0.9109
Medford-Ashland, OR................................. 1.0033 1.0023
Memphis, TN-AR-MS................................... 0.8793 0.9157
Miami, FL........................................... 0.9950 0.9966
Milwaukee-Waukesha, WI.............................. 0.9865 0.9907
Minneapolis-St. Paul, MN-WI......................... 1.0930 1.0628
Missoula, MT........................................ 0.9177 0.9429
Mobile, AL.......................................... 0.8084 0.8645
Modesto, CA......................................... 1.0820 1.0555
Monmouth-Ocean, NJ.................................. 1.1257 1.0845
Monroe, LA.......................................... 0.8097 0.8654
Montgomery, AL...................................... 0.7400 0.8137
Myrtle Beach, SC.................................... 0.8577 0.9002
[[Page 40047]]
Nashville, TN....................................... 0.9552 0.9691
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2294 1.1519
New London-Norwich, CT.............................. 1.1526 1.1021
New Orleans, LA..................................... 0.9036 0.9329
New York, NY........................................ 1.4287 1.2767
Newark, NJ.......................................... 1.1622 1.1084
Newburgh, NY-PA..................................... 1.0797 1.0539
Oakland, CA......................................... 1.5319 1.3392
Odessa-Midland, TX.................................. 0.9495 0.9651
Oklahoma City, OK................................... 0.8694 0.9086
Omaha, NE-IA........................................ 0.9712 0.9802
Orange County, CA................................... 1.1246 1.0837
Orlando, FL......................................... 0.9642 0.9753
Peoria-Pekin, IL.................................... 0.8773 0.9143
Philadelphia, PA-NJ................................. 1.0947 1.0639
Pine Bluff, AR...................................... 0.7895 0.8506
Pittsburgh, PA...................................... 0.9419 0.9598
Pittsfield, MA...................................... 0.9904 0.9934
Pocatello, ID....................................... 0.9159 0.9416
Portland, ME........................................ 0.9427 0.9604
Portland-Vancouver, OR-WA........................... 1.1150 1.0774
Provo-Orem, UT...................................... 0.9843 0.9892
Raleigh-Durham-Chapel Hill, NC...................... 0.9818 0.9875
Rapid City, SD...................................... 0.8869 0.9211
Reading, PA......................................... 0.9216 0.9456
Redding, CA......................................... 1.1155 1.0777
Reno, NV............................................ 1.0421 1.0286
Richland-Kennewick-Pasco, WA........................ 1.0356 1.0242
Richmond-Petersburg, VA............................. 0.9678 0.9778
Roanoke, VA......................................... 0.8371 0.8854
Rochester, MN....................................... 1.1462 1.0979
Rockford, IL........................................ 0.9042 0.9334
Sacramento, CA...................................... 1.1831 1.1220
Saginaw-Bay City-Midland, MI........................ 0.9590 0.9717
St. Cloud, MN....................................... 0.9919 0.9944
St. Joseph, MO...................................... 0.8121 0.8672
St. Louis, MO-IL.................................... 0.8931 0.9255
Salinas, CA......................................... 1.4570 1.2940
Salt Lake City-Ogden, UT............................ 0.9863 0.9906
San Diego, CA....................................... 1.1265 1.0850
Santa Fe, NM........................................ 0.9765 0.9838
Santa Rosa, CA...................................... 1.2631 1.1734
Sarasota-Bradenton, FL.............................. 1.0090 1.0062
Savannah, GA........................................ 0.9243 0.9475
Seattle-Bellevue-Everett, WA........................ 1.1361 1.0913
Sherman-Denison, TX................................. 0.9003 0.9306
Shreveport-Bossier City, LA......................... 0.9050 0.9339
Sioux City, IA-NE................................... 0.8767 0.9138
Sioux Falls, SD..................................... 0.8939 0.9261
South Bend, IN...................................... 0.9993 0.9995
Spokane, WA......................................... 1.0668 1.0453
Springfield, IL..................................... 0.8571 0.8998
Springfield, MO..................................... 0.8357 0.8843
Stockton-Lodi, CA................................... 1.0988 1.0666
Syracuse, NY........................................ 0.9621 0.9739
Tampa-St. Petersburg-Clearwater, FL................. 0.8925 0.9251
Texarkana,AR-Texarkana, TX.......................... 0.8327 0.8822
Toledo, OH.......................................... 0.9809 0.9869
Topeka, KS.......................................... 0.8749 0.9125
Tucson, AZ.......................................... 0.8976 0.9287
Tulsa, OK........................................... 0.8760 0.9133
Tuscaloosa, AL...................................... 0.8171 0.8708
Tyler, TX........................................... 0.9359 0.9556
Victoria, TX........................................ 0.8328 0.8822
Waco, TX............................................ 0.8150 0.8693
Washington, DC-MD-VA-WV............................. 1.0854 1.0577
Waterloo-Cedar Falls, IA............................ 0.8677 0.9074
Wausau, WI.......................................... 0.9558 0.9695
West Palm Beach-Boca Raton, FL...................... 0.9777 0.9847
Wichita, KS......................................... 0.9237 0.9471
Wichita Falls, TX................................... 0.7946 0.8543
Wilmington-Newark, DE-MD............................ 1.0877 1.0593
Rural Alabama....................................... 0.7528 0.8233
Rural Florida....................................... 0.8794 0.9158
Rural Illinois (IA Hospitals)....................... 0.8147 0.8691
Rural Illinois (MO Hospitals)....................... 0.8053 0.8622
Rural Kentucky...................................... 0.7963 0.8556
Rural Louisiana..................................... 0.7692 0.8355
Rural Minnesota..................................... 0.9035 0.9329
Rural Missouri...................................... 0.7899 0.8509
Rural Montana....................................... 0.8655 0.9058
Rural Nebraska...................................... 0.8142 0.8687
Rural Nevada........................................ 0.9161 0.9418
Rural Oregon........................................ 1.0038 1.0026
Rural Texas......................................... 0.7714 0.8372
Rural Washington.................................... 1.0209 1.0143
Rural Wisconsin..................................... 0.9068 0.9352
Rural Wyoming....................................... 0.8747 0.9124
------------------------------------------------------------------------
Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Wage
Index-- GAF--
Area Wage Index GAF Reclass. Reclass.
Hospitals Hospitals
----------------------------------------------------------------------------------------------------------------
\1\ Aguadilla, PR........................................... 1.0025 1.0017 ........... ...........
\1\ Arecibo, PR............................................. 1.0025 1.0017 ........... ...........
\1\ Caguas, PR.............................................. 1.0025 1.0017 1.0025 1.0017
Mayaguez, PR................................................ 1.0084 1.0057 ........... ...........
Ponce, PR................................................... 1.0825 1.0558 ........... ...........
\1\ San Juan-Bayamon, PR.................................... 1.0025 1.0017 ........... ...........
Rural Puerto Rico........................................... 1.0025 1.0017 ........... ...........
----------------------------------------------------------------------------------------------------------------
\1\ Hospitals geographically located in the area are assigned the Rural Puerto Rico wage index for FY 2002.
Table 4G.--Pre-Reclassified Wage Index for Urban Areas
------------------------------------------------------------------------
Wage
Urban Area (Constituent Counties) Index
------------------------------------------------------------------------
0040 Abilene, TX............................................. 0.7965
Taylor, TX
0060 Aguadilla, PR........................................... 0.4683
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH............................................... 0.9876
Portage, OH
Summit, OH
0120 Albany, GA.............................................. 1.0640
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY............................. 0.8500
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
[[Page 40048]]
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM......................................... 0.9750
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA.......................................... 0.8029
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA.......................... 1.0077
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA............................................. 0.9126
Blair, PA
0320 Amarillo, TX............................................ 0.8711
Potter, TX
Randall, TX
0380 Anchorage, AK........................................... 1.2570
Anchorage, AK
0440 Ann Arbor, MI........................................... 1.1098
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL............................................ 0.8276
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI............................. 0.9241
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR............................................. 0.4630
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC........................................... 0.9200
Buncombe, NC
Madison, NC
0500 Athens, GA.............................................. 0.9842
Clarke, GA
Madison, GA
Oconee, GA
0520 Atlanta, GA............................................. 1.0058
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................................... 1.1293
Atlantic, NJ
Cape May, NJ
0580 Auburn-Opelika, AL...................................... 0.8230
Lee, AL
0600 Augusta-Aiken, GA-SC.................................... 0.9970
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX................................... 0.9597
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA......................................... 0.9470
Kern, CA
0720 Baltimore, MD........................................... 0.9856
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.............................................. 0.9593
Penobscot, ME
0743 Barnstable-Yarmouth, MA................................. 1.3626
Barnstable, MA
0760 Baton Rouge, LA......................................... 0.8149
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX................................ 0.8442
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA.......................................... 1.1826
Whatcom, WA
0870 Benton Harbor, MI....................................... 0.8810
Berrien, MI
0875 Bergen-Passaic, NJ...................................... 1.1689
Bergen, NJ
Passaic, NJ
0880 Billings, MT............................................ 0.9352
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS.......................... 0.8440
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY.......................................... 0.8446
Broome, NY
Tioga, NY
1000 Birmingham, AL.......................................... 0.8808
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND............................................ 0.7984
Burleigh, ND
Morton, ND
1020 Bloomington, IN......................................... 0.8842
Monroe, IN
1040 Bloomington-Normal, IL.................................. 0.9038
McLean, IL
1080 Boise City, ID.......................................... 0.9050
Ada, ID
Canyon, ID
1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH (NH 1.1289
Hospitals)...................................................
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.................................... 0.9799
Boulder, CO
1145 Brazoria, TX........................................... 0.8209
Brazoria, TX
1150 Bremerton, WA........................................... 1.0758
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.................... 0.9012
Cameron, TX
1260 Bryan-College Station, TX............................... 0.9328
Brazos, TX
1280 Buffalo-Niagara Falls, NY............................... 0.9459
Erie, NY
Niagara, NY
1303 Burlington, VT.......................................... 0.9883
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.............................................. 0.4699
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH.................................... 0.8956
Carroll, OH
Stark, OH
1350 Casper, WY.............................................. 0.9496
Natrona, WY
1360 Cedar Rapids, IA........................................ 0.8699
Linn, IA
1400 Champaign-Urbana, IL.................................... 0.9306
Champaign, IL
1440 Charleston-North Charleston, SC......................... 0.9206
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV.......................................... 0.9264
Kanawha, WV
Putnam, WV
1520 Charlotte-Gastonia-Rock Hill, NC-SC..................... 0.9348
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA..................................... 1.0566
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA...................................... 0.9369
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
[[Page 40049]]
Marion, TN
1580 Cheyenne, WY............................................ 0.8288
Laramie, WY
1600 Chicago, IL............................................. 1.1046
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA...................................... 0.9856
Butte, CA
1640 Cincinnati, OH-KY-IN.................................... 0.9473
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......................... 0.8337
Christian, KY
Montgomery, TN
1680 Cleveland-Lorain-Elyria, OH............................. 0.9457
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.................................... 0.9744
El Paso, CO
1740 Columbia, MO............................................ 0.8686
Boone, MO
1760 Columbia, SC............................................ 0.9492
Lexington, SC
Richland, SC
1800 Columbus, GA-ALRussell, AL.............................. 0.8440
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 Columbus, OH............................................ 0.9565
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX...................................... 0.8341
Nueces, TX
San Patricio, TX
1890 Corvallis, OR........................................... 1.1646
Benton, OR
1900 Cumberland, MD-WV (WV Hospital)......................... 0.8306
Allegany, MD
Mineral, WV
1920 Dallas, TX.............................................. 0.9936
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA............................................ 0.8613
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL..................... 0.8638
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH.................................. 0.9225
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL....................................... 0.8982
Flagler, FL
Volusia, FL
2030 Decatur, AL............................................. 0.8775
Lawrence, AL
Morgan, AL
2040 Decatur, IL............................................. 0.7987
Macon, IL
2080 Denver, CO.............................................. 1.0328
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA.......................................... 0.8779
Dallas, IA
Polk, IA
Warren, IA
2160 Detroit, MI............................................. 1.0487
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.............................................. 0.7948
Dale, AL
Houston, AL
2190 Dover, DE............................................... 1.0296
Kent, DE
2200 Dubuque, IA............................................. 0.8519
Dubuque, IA
2240 Duluth-Superior, MN-WI.................................. 1.0284
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY..................................... 1.0532
Dutchess, NY
2290 Eau Claire, WI.......................................... 0.8832
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX............................................. 0.9215
El Paso, TX
2330 Elkhart-Goshen, IN...................................... 0.9638
Elkhart, IN
2335 Elmira, NY.............................................. 0.8415
Chemung, NY
2340 Enid, OK................................................ 0.8357
Garfield, OK
2360 Erie, PA................................................ 0.8716
Erie, PA
2400 Eugene-Springfield, OR.................................. 1.1471
Lane, OR
2440 Evansville-Henderson, IN-KY (IN Hospitals).............. 0.8514
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN................................... 0.9267
Clay, MN
Cass, ND
2560 Fayetteville, NC........................................ 0.9027
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR...................... 0.8445
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT........................................ 1.0556
Coconino, AZ
Kane, UT
2640 Flint, MI............................................... 1.0913
Genesee, MI
2650 Florence, AL............................................ 0.7845
Colbert, AL
Lauderdale, AL
2655 Florence, SC............................................ 0.8722
Florence, SC
2670 Fort Collins-Loveland, CO............................... 1.0045
Larimer, CO
2680 Ft. Lauderdale, FL...................................... 1.0293
Broward, FL
2700 Fort Myers-Cape Coral, FL............................... 0.9374
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL.......................... 1.0214
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK....................................... 0.8053
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL................................... 0.9002
Okaloosa, FL
2760 Fort Wayne, IN.......................................... 0.9203
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 Forth Worth-Arlington, TX............................... 0.9394
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.............................................. 0.9887
Fresno, CA
Madera, CA
2880 Gadsden, AL.............................................
Etowah, AL 0.8792
2900 Gainesville, FL......................................... 0.9481
Alachua, FL
2920 Galveston-Texas City, TX................................ 1.0313
Galveston, TX
2960 Gary, IN................................................ 0.9530
Lake, IN
Porter, IN
2975 Glens Falls, NY......................................... 0.8336
Warren, NY
Washington, NY
2980 Goldsboro, NC........................................... 0.8709
[[Page 40050]]
Wayne, NC
2985 Grand Forks, ND-MN...................................... 0.9069
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO...................................... 0.9569
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI....................... 1.0048
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT......................................... 0.8870
Cascade, MT
3060 Greeley, CO............................................. 0.9495
Weld, CO
3080 Green Bay, WI........................................... 0.9208
Brown, WI
3120 Greensboro-Winston-Salem-High Point, NC................. 0.9539
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC.......................................... 0.9289
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC..................... 0.9217
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD.......................................... 0.8365
Washington, MD
3200 Hamilton-Middletown, OH................................. 0.9287
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA......................... 0.9425
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 Hartford, CT............................................ 1.1533
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 \2\ Hattiesburg, MS..................................... 0.7476
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC............................ 0.9367
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI............................................ 1.1539
Honolulu, HI
3350 Houma, LA............................................... 0.7951
Lafourche, LA
Terrebonne, LA
3360 Houston, TX............................................. 0.9631
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH............................ 0.9616
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL.......................................... 0.8883
Limestone, AL
Madison, AL
3480 Indianapolis, IN........................................ 0.9698
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA........................................... 0.9859
Johnson, IA
3520 Jackson, MI............................................. 0.9257
Jackson, MI
3560 Jackson, MS............................................. 0.8491
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN............................................. 0.9013
Madison, TN
Chester, TN
3600 Jacksonville, FL........................................ 0.9223
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC........................................ 0.7622
Onslow, NC
3610 Jamestown, NY........................................... 0.8050
Chautauqua, NY
3620 Janesville-Beloit, WI................................... 0.9739
Rock, WI
3640 Jersey City, NJ......................................... 1.1178
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA................... 0.8617
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA........................................... 0.8723
Cambria, PA
Somerset, PA
3700 Jonesboro, AR........................................... 0.8425
Craighead, AR
3710 Joplin, MO.............................................. 0.8727
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI............................... 1.0639
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL............................................ 0.9889
Kankakee, IL
3760 Kansas City, KS-MO...................................... 0.9536
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............................................. 0.9568
Kenosha, WI
3810 Killeen-Temple, TX...................................... 0.7292
Bell, TX
Coryell, TX
3840 Knoxville, TN........................................... 0.8890
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.............................................. 0.9126
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN........................................ 0.9250
Houston, MN
La Crosse, WI
3880 Lafayette, LA........................................... 0.8526
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN........................................... 0.9121
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA........................................ 0.7765
Calcasieu, LA
3980 Lakeland-Winter Haven, FL............................... 0.9067
Polk, FL
4000 Lancaster, PA........................................... 0.9296
Lancaster, PA
4040 Lansing-East Lansing, MI................................ 0.9653
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.............................................. 0.7849
Webb, TX
4100 Las Cruces, NM.......................................... 0.8621
Dona Ana, NM
4120 Las Vegas, NV-AZ........................................ 1.1182
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS............................................ 0.8656
Douglas, KS
4200 Lawton, OK.............................................. 0.8682
Comanche, OK
4243 Lewiston-Auburn, ME..................................... 0.9287
Androscoggin, ME
4280 Lexington, KY........................................... 0.8791
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
[[Page 40051]]
Scott, KY
Woodford, KY
4320 Lima, OH................................................ 0.9470
Allen, OH
Auglaize, OH
4360 Lincoln, NE............................................. 1.0173
Lancaster, NE
4400 Little Rock-North Little Rock, AR....................... 0.8955
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX................................... 0.8571
Gregg, TX
Harrison, TX
Upshur, TX
4480 Los Angeles-Long Beach, CA.............................. 1.1948
Los Angeles, CA
4520 \1\ Louisville, KY-IN................................... 0.9529
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX............................................. 0.8449
Lubbock, TX
4640 Lynchburg, VA........................................... 0.9103
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA............................................... 0.8957
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI............................................. 1.0337
Dane, WI
4800 Mansfield, OH........................................... 0.8708
Crawford, OH
Richland, OH
4840 Mayaguez, PR............................................ 0.4860
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX............................ 0.8378
Hidalgo, TX
4890 Medford-Ashland, OR.................................... 1.0314
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL....................... 0.9913
Brevard, Fl
4920 Memphis, TN-AR-MS....................................... 0.8978
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.............................................. 0.9757
Merced, CA
5000 Miami, FL............................................... 0.9950
Dade, FL
5015 Middlesex-Somerset-Hunterdon, NJ........................ 1.1469
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 Milwaukee-Waukesha, WI.................................. 0.9971
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 Minneapolis-St. Paul, MN-WI............................. 1.0930
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............................................ 0.9364
Missoula, MT
5160 Mobile, AL.............................................. 0.8082
Baldwin, AL
Mobile, AL
5170 Modesto, CA............................................. 1.0820
Stanislaus, CA
5190 Monmouth-Ocean, NJ...................................... 1.0872
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.............................................. 0.8201
Ouachita, LA
5240 Montgomery, AL.......................................... 0.7359
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.............................................. 0.9939
Delaware, IN
5330 Myrtle Beach, SC........................................ 0.8771
Horry, SC
5345 Naples, FL.............................................. 0.9699
Collier, FL
5360 Nashville, TN........................................... 0.9754
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 Nassau-Suffolk, NY...................................... 1.3643
Nassau, NY
Suffolk, NY
5483 New Haven-Bridgeport-Stamford-Waterbury-................ 1.2238
Danbury, CT
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT.................................. 1.1526
New London, CT
5560 New Orleans, LA......................................... 0.9036
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............................................ 1.4427
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 Newark, NJ.............................................. 1.1622
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA......................................... 1.1113
Orange, NY
Pike, PA
5720 Norfolk-Virginia Beach-Newport News, VA-NC.............. 0.8579
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............................................. 1.5319
Alameda, CA
Contra Costa, CA
5790 Ocala, FL............................................... 0.9556
Marion, FL
5800 Odessa-Midland, TX...................................... 1.0104
Ector, TX
Midland, TX
5880 Oklahoma City, OK....................................... 0.8694
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA............................................ 1.1350
Thurston, WA
5920 Omaha, NE-IA............................................ 0.9712
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 Orange County, CA....................................... 1.1123
Orange, CA
5960 Orlando, FL............................................. 0.9642
Lake, FL
Orange, FL
[[Page 40052]]
Osceola, FL
Seminole, FL
5990 Owensboro, KY........................................... 0.8334
Daviess, KY
6015 Panama City, FL........................................ 0.9061
Bay, FL
6020 Parkersburg-Marietta, WV-OH............................. 0.8133
Washington, OH
Wood, WV
6080 Pensacola, FL........................................... 0.8329
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL........................................ 0.8773
Peoria, IL
Tazewell, IL
Woodford, IL
6160 Philadelphia, PA-NJ..................................... 1.0947
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 Phoenix-Mesa, AZ........................................ 0.9638
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR.......................................... 0.7895
Jefferson, AR
6280 Pittsburgh, PA.......................................... 0.9560
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA.......................................... 1.0278
Berkshire, MA
6340 Pocatello, ID........................................... 0.9448
Bannock, ID
6360 Ponce, PR............................................... 0.5218
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME............................................ 0.9427
Cumberland, ME
Sagadahoc, ME
York, ME
6440 Portland-Vancouver, OR-WA............................... 1.1111
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 Providence-Warwick-Pawtucket, RI........................ 1.0805
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT.......................................... 0.9843
Utah, UT
6560 Pueblo, CO.............................................. 0.8604
Pueblo, CO
6580 Punta Gorda, FL......................................... 0.9015
Charlotte, FL
6600 Racine, WI.............................................. 0.9333
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC.......................... 0.9818
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD.......................................... 0.8869
Pennington, SD
6680 Reading, PA............................................. 0.9583
Berks, PA
6690 Redding, CA............................................. 1.1155
Shasta, CA
6720 Reno, NV................................................ 1.0440
Washoe, NV
6740 Richland-Kennewick-Pasco, WA............................ 1.0960
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA................................. 0.9678
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............................ 1.1111
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA............................................. 0.8371
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN........................................... 1.1462
Olmsted, MN
6840 Rochester, NY........................................... 0.9347
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL............................................ 0.9204
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC......................................... 0.9109
Edgecombe, NC
Nash, NC
6920 Sacramento, CA.......................................... 1.1831
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI............................ 0.9590
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN........................................... 0.9851
Benton, MN
Stearns, MN
7000 St. Joseph, MO.......................................... 0.9009
Andrew, MO
Buchanan, MO
7040 St. Louis, MO-IL........................................ 0.8931
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............................................... 1.0011
Marion, OR
Polk, OR
7120 Salinas, CA............................................. 1.4684
Monterey, CA
7160 Salt Lake City-Ogden, UT................................ 0.9863
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX.......................................... 0.8193
Tom Green, TX
7240 San Antonio, TX......................................... 0.8584
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 San Diego, CA........................................... 1.1265
San Diego, CA
7360 San Francisco, CA....................................... 1.4140
Marin, CA
San Francisco, CA
San Mateo, CA
7400 San Jose, CA............................................ 1.4193
Santa Clara, CA
7440 San Juan-Bayamon, PR.................................... 0.4762
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
[[Page 40053]]
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.............. 1.0990
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.................... 1.0802
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.............................. 1.3970
Santa Cruz, CA
7490 Santa Fe, NM............................................ 1.0194
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA......................................... 1.3034
Sonoma, CA
7510 Sarasota-Bradenton, FL.................................. 1.0090
Manatee, FL
Sarasota, FL
7520 Savannah, GA............................................ 0.9243
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA.................... 0.8683
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 Seattle-Bellevue-Everett, WA............................ 1.1361
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA.............................................. 0.7926
Mercer, PA
7620 Sheboygan, WI........................................... 0.8427
Sheboygan, WI
7640 Sherman-Denison, TX..................................... 0.9373
Grayson, TX
7680 Shreveport-Bossier City, LA............................ 0.9050
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE....................................... 0.8767
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD......................................... 0.9139
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN.......................................... 0.9993
St. Joseph, IN
7840 Spokane, WA............................................. 1.0668
Spokane, WA
7880 Springfield, IL......................................... 0.8676
Menard, IL
Sangamon, IL
7920 Springfield, MO......................................... 0.8567
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA......................................... 1.0881
Hampden, MA
Hampshire, MA
8050 State College, PA....................................... 0.9133
Centre, PA
8080 Steubenville-Weirton, OH-WV (WV Hospitals).............. 0.8637
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA....................................... 1.0815
San Joaquin, CA
8140 Sumter, SC.............................................. 0.7794
Sumter, SC
8160 Syracuse, NY............................................ 0.9621
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.............................................. 1.1616
Pierce, WA
8240 Tallahassee, FL......................................... 0.8527
Gadsden, FL
Leon, FL
8280 Tampa-St. Petersburg-Clearwater, FL..................... 0.8925
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN......................................... 0.8532
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana,AR-Texarkana, TX.............................. 0.8327
Miller, AR
Bowie, TX
8400 Toledo, OH.............................................. 0.9809
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.............................................. 0.8912
Shawnee, KS
8480 Trenton, NJ............................................ 1.0416
Mercer, NJ
8520 Tucson, AZ.............................................. 0.8967
Pima, AZ
8560 Tulsa, OK............................................... 0.8902
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL.......................................... 0.8171
Tuscaloosa, AL
8640 Tyler, TX............................................... 0.9641
Smith, TX
8680 Utica-Rome, NY.......................................... 0.8329
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.............................. 1.3562
Napa, CA
Solano, CA
8735 Ventura, CA............................................. 1.0994
Ventura, CA
8750 Victoria, TX............................................ 0.8328
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ........................ 1.0441
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA.......................... 0.9610
Tulare, CA
8800 Waco, TX................................................ 0.8129
McLennan, TX
8840 Washington, DC-MD-VA-WV................................. 1.0962
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................................ 0.8041
Black Hawk, IA
8940 Wausau, WI.............................................. 0.9696
Marathon, WI
8960 West Palm Beach-Boca Raton, FL.......................... 0.9777
Palm Beach, FL
9000 Wheeling, WV-OH......................................... 0.7985
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS............................................. 0.9606
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX....................................... 0.7867
Archer, TX
Wichita, TX
9140 Williamsport, PA........................................ 0.8521
Lycoming, PA
9160 Wilmington-Newark, DE-MD................................ 1.0877
New Castle, DE
Cecil, MD
9200 Wilmington, NC.......................................... 0.9409
New Hanover, NC
Brunswick, NC
9260 Yakima, WA.............................................. 1.0567
Yakima, WA
9270 Yolo, CA................................................ 0.9701
Yolo, CA
9280 York, PA................................................ 0.9441
York, PA
9320 Youngstown-Warren, OH................................... 0.9563
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA........................................... 1.0359
Sutter, CA
Yuba, CA
9360 Yuma, AZ................................................ 0.8989
Yuma, AZ
------------------------------------------------------------------------
[[Page 40054]]
Table 4H.--Pre-Reclassified Wage Index for Rural Areas
------------------------------------------------------------------------
Wage
Nonurban Area Index
------------------------------------------------------------------------
Alabama....................................................... 0.7339
Alaska........................................................ 1.1862
Arizona....................................................... 0.8681
Arkansas...................................................... 0.7489
California.................................................... 0.9772
Colorado...................................................... 0.8811
Connecticut................................................... 1.2077
Delaware...................................................... 0.9589
Florida....................................................... 0.8812
Georgia....................................................... 0.8295
Hawaii........................................................ 1.1112
Idaho......................................................... 0.8718
Illinois...................................................... 0.8053
Indiana....................................................... 0.8721
Iowa.......................................................... 0.8147
Kansas........................................................ 0.7769
Kentucky...................................................... 0.7963
Louisiana..................................................... 0.7601
Maine......................................................... 0.8721
Maryland...................................................... 0.8859
Massachusetts................................................. 1.1454
Michigan...................................................... 0.9010
Minnesota..................................................... 0.9035
Mississippi................................................... 0.7528
Missouri...................................................... 0.7778
Montana....................................................... 0.8655
Nebraska...................................................... 0.8142
Nevada........................................................ 0.9673
New Hampshire................................................. 0.9803
New Jersey \1\................................................ ........
New Mexico.................................................... 0.8676
New York...................................................... 0.8547
North Carolina................................................ 0.8539
North Dakota.................................................. 0.7879
Ohio.......................................................... 0.8668
Oklahoma...................................................... 0.7566
Oregon........................................................ 1.0027
Pennsylvania.................................................. 0.8617
Puerto Rico................................................... 0.4800
Rhode Island \1\.............................................. ........
South Carolina................................................ 0.8512
South Dakota.................................................. 0.7861
Tennessee..................................................... 0.7928
Texas......................................................... 0.7712
Utah.......................................................... 0.9051
Vermont....................................................... 0.9466
Virginia...................................................... 0.8241
Washington.................................................... 1.0209
West Virginia................................................. 0.8067
Wisconsin..................................................... 0.9079
Wyoming....................................................... 0.8747
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
--------------------
* Medicare data have been supplemented by data from 19 states for low
volume DRGs.
** DRGs 469 and 470 contain cases which could not be assigned to valid
DRGs.
Note: Geometric mean is used only to determine payment for transfer
cases.
Note: Arithmetic mean is presented for informational purposes only.
Note: Relative weights are based on Medicare patient data and may not be
appropriate for other patients.
[[Page 40054]]
Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean
Length of Stay
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic
DRG MDC Type DRG title weights mean LOS mean LOS
----------------------------------------------------------------------------------------------------------------
1............... 01 SURG CRANIOTOMY AGE >17 EXCEPT 3.2713 7.6 10.2
FOR TRAUMA.
2............... 01 SURG CRANIOTOMY FOR TRAUMA AGE 3.3874 8.8 11.1
>17.
3............... 01 SURG *CRANIOTOMY AGE 0-17....... 1.9594 12.7 12.7
4............... 01 SURG SPINAL PROCEDURES.......... 2.4148 5.5 8.1
5............... 01 SURG EXTRACRANIAL VASCULAR 1.3628 2.3 3.2
PROCEDURES.
6............... 01 SURG CARPAL TUNNEL RELEASE...... .7230 2.1 3.0
7............... 01 SURG PERIPH & CRANIAL NERVE & 2.6285 8.3 11.1
OTHER NERV SYST PROC W CC.
8............... 01 SURG PERIPH & CRANIAL NERVE & 1.3953 2.0 2.9
OTHER NERV SYST PROC W/O
CC.
9............... 01 MED SPINAL DISORDERS & INJURIES 1.3350 5.2 6.9
10.............. 01 MED NERVOUS SYSTEM NEOPLASMS W 1.2690 5.5 7.2
CC.
11.............. 01 MED NERVOUS SYSTEM NEOPLASMS W/ .8471 3.3 4.3
O CC.
12.............. 01 MED DEGENERATIVE NERVOUS SYSTEM .9020 4.9 6.3
DISORDERS.
13.............. 01 MED MULTIPLE SCLEROSIS & .8129 4.5 5.5
CEREBELLAR ATAXIA.
14.............. 01 MED SPECIFIC CEREBROVASCULAR 1.1655 4.8 6.1
DISORDERS EXCEPT TIA.
15.............. 01 MED TRANSIENT ISCHEMIC ATTACK & .7349 3.0 3.7
PRECEREBRAL OCCLUSIONS.
16.............. 01 MED NONSPECIFIC CEREBROVASCULAR 1.1867 5.1 6.5
DISORDERS W CC.
17.............. 01 MED NONSPECIFIC CEREBROVASCULAR .6689 2.7 3.4
DISORDERS W/O CC.
18.............. 01 MED CRANIAL & PERIPHERAL NERVE .9744 4.6 5.8
DISORDERS W CC.
19.............. 01 MED CRANIAL & PERIPHERAL NERVE .6756 3.0 3.8
DISORDERS W/O CC.
20.............. 01 MED NERVOUS SYSTEM INFECTION 2.7764 9.0 11.4
EXCEPT VIRAL MENINGITIS.
21.............. 01 MED VIRAL MENINGITIS........... 1.4573 5.5 7.1
22.............. 01 MED HYPERTENSIVE ENCEPHALOPATHY 1.0037 4.0 5.1
23.............. 01 MED NONTRAUMATIC STUPOR & COMA. .8069 3.4 4.4
24.............. 01 MED SEIZURE & HEADACHE AGE >17 1.0172 4.0 5.3
W CC.
25.............. 01 MED SEIZURE & HEADACHE AGE >17 .5947 2.7 3.3
W/O CC.
26.............. 01 MED SEIZURE & HEADACHE AGE 0-17 .5981 2.4 3.0
27.............. 01 MED TRAUMATIC STUPOR & COMA, 1.3514 3.7 5.6
COMA >1 HR.
28.............. 01 MED TRAUMATIC STUPOR & COMA, 1.3609 5.2 6.8
COMA 1 HR AGE >17 W CC.
29.............. 01 MED TRAUMATIC STUPOR & COMA, .6956 3.0 3.8
COMA 1 HR AGE >17 W/O CC.
30.............. 01 MED *TRAUMATIC STUPOR & COMA, .3314 2.0 2.0
COMA 1 HR AGE 0-17.
31.............. 01 MED CONCUSSION AGE >17 W CC.... .9165 3.5 4.8
32.............. 01 MED CONCUSSION AGE >17 W/O CC.. .5230 2.0 2.6
33.............. 01 MED *CONCUSSION AGE 0-17....... .2082 1.6 1.6
34.............. 01 MED OTHER DISORDERS OF NERVOUS 1.0074 4.2 5.4
SYSTEM W CC.
35.............. 01 MED OTHER DISORDERS OF NERVOUS .5885 2.7 3.5
SYSTEM W/O CC.
36.............. 02 SURG RETINAL PROCEDURES......... .6615 1.2 1.5
37.............. 02 SURG ORBITAL PROCEDURES......... 1.1300 2.9 4.3
38.............. 02 SURG PRIMARY IRIS PROCEDURES.... .4751 2.0 2.6
39.............. 02 SURG LENS PROCEDURES WITH OR .5986 1.5 1.9
WITHOUT VITRECTOMY.
40.............. 02 SURG EXTRAOCULAR PROCEDURES .8264 2.4 3.6
EXCEPT ORBIT AGE >17.
[[Page 40055]]
41.............. 02 SURG *EXTRAOCULAR PROCEDURES .3374 1.6 1.6
EXCEPT ORBIT AGE 0-17.
42.............. 02 SURG INTRAOCULAR PROCEDURES .6302 1.6 2.3
EXCEPT RETINA, IRIS & LENS.
43.............. 02 MED HYPHEMA.................... .4578 2.8 3.3
44.............. 02 MED ACUTE MAJOR EYE INFECTIONS. .6554 4.3 5.2
45.............. 02 MED NEUROLOGICAL EYE DISORDERS. .6760 2.7 3.3
46.............. 02 MED OTHER DISORDERS OF THE EYE .7962 3.9 5.0
AGE >17 W CC.
47.............. 02 MED OTHER DISORDERS OF THE EYE .5043 2.7 3.4
AGE >17 W/O CC.
48.............. 02 MED *OTHER DISORDERS OF THE EYE .2972 2.9 2.9
AGE 0-17.
49.............. 03 SURG MAJOR HEAD & NECK 1.7649 3.8 5.1
PROCEDURES.
50.............. 03 SURG SIALOADENECTOMY............ .8158 1.5 1.9
51.............. 03 SURG SALIVARY GLAND PROCEDURES .7895 1.8 2.7
EXCEPT SIALOADENECTOMY.
52.............. 03 SURG CLEFT LIP & PALATE REPAIR.. .7590 1.5 1.9
53.............. 03 SURG SINUS & MASTOID PROCEDURES 1.1773 2.3 3.7
AGE >17.
54.............. 03 SURG *SINUS & MASTOID PROCEDURES .4817 3.2 3.2
AGE 0-17.
55.............. 03 SURG MISCELLANEOUS EAR, NOSE, .8483 1.8 2.7
MOUTH & THROAT PROCEDURES.
56.............. 03 SURG RHINOPLASTY................ .8787 2.0 2.7
57.............. 03 SURG T&A PROC, EXCEPT 1.2004 2.8 4.3
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE
>17.
58.............. 03 SURG *T&A PROC, EXCEPT .2735 1.5 1.5
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE 0-
17.
59.............. 03 SURG TONSILLECTOMY &/OR .8276 1.9 2.8
ADENOIDECTOMY ONLY, AGE
>17.
60.............. 03 SURG *TONSILLECTOMY &/OR .2083 1.5 1.5
ADENOIDECTOMY ONLY, AGE 0-
17.
61.............. 03 SURG MYRINGOTOMY W TUBE 1.3541 3.3 5.7
INSERTION AGE >17.
62.............. 03 SURG *MYRINGOTOMY W TUBE .2950 1.3 1.3
INSERTION AGE 0-17.
63.............. 03 SURG OTHER EAR, NOSE, MOUTH & 1.3718 3.3 4.7
THROAT O.R. PROCEDURES.
64.............. 03 MED EAR, NOSE, MOUTH & THROAT 1.2319 4.8 6.8
MALIGNANCY.
65.............. 03 MED DYSEQUILIBRIUM............. .5326 2.4 2.9
66.............. 03 MED EPISTAXIS.................. .5536 2.6 3.3
67.............. 03 MED EPIGLOTTITIS............... .7514 3.0 3.7
68.............. 03 MED OTITIS MEDIA & URI AGE >17 .6665 3.6 4.3
W CC.
69.............. 03 MED OTITIS MEDIA & URI AGE >17 .4948 2.8 3.4
W/O CC.
70.............. 03 MED OTITIS MEDIA & URI AGE 0-17 .4575 2.5 3.0
71.............. 03 MED LARYNGOTRACHEITIS.......... .6685 3.1 4.0
72.............. 03 MED NASAL TRAUMA & DEFORMITY... .6699 2.9 3.7
73.............. 03 MED OTHER EAR, NOSE, MOUTH & .7993 3.6 4.7
THROAT DIAGNOSES AGE >17.
74.............. 03 MED *OTHER EAR, NOSE, MOUTH & .3352 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75.............. 04 SURG MAJOR CHEST PROCEDURES..... 3.2096 8.8 10.8
76.............. 04 SURG OTHER RESP SYSTEM O.R. 3.0129 10.1 12.7
PROCEDURES W CC.
77.............. 04 SURG OTHER RESP SYSTEM O.R. 1.2416 4.1 5.5
PROCEDURES W/O CC.
78.............. 04 MED PULMONARY EMBOLISM......... 1.3295 6.3 7.2
79.............. 04 MED RESPIRATORY INFECTIONS & 1.7094 7.6 9.3
INFLAMMATIONS AGE >17 W CC.
80.............. 04 MED RESPIRATORY INFECTIONS & .9215 5.0 6.0
INFLAMMATIONS AGE >17 W/O
CC.
81.............. 04 MED *RESPIRATORY INFECTIONS & 1.5177 6.1 6.1
INFLAMMATIONS AGE 0-17.
82.............. 04 MED RESPIRATORY NEOPLASMS...... 1.4316 6.0 7.6
83.............. 04 MED MAJOR CHEST TRAUMA W CC.... .9803 4.8 5.9
84.............. 04 MED MAJOR CHEST TRAUMA W/O CC.. .5454 2.8 3.5
85.............. 04 MED PLEURAL EFFUSION W CC...... 1.2483 5.5 6.9
86.............. 04 MED PLEURAL EFFUSION W/O CC.... .6769 3.0 3.8
87.............. 04 MED PULMONARY EDEMA & 1.4282 5.5 6.9
RESPIRATORY FAILURE.
88.............. 04 MED CHRONIC OBSTRUCTIVE .9127 4.5 5.4
PULMONARY DISEASE.
89.............. 04 MED SIMPLE PNEUMONIA & PLEURISY 1.0601 5.3 6.3
AGE >17 W CC.
90.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .6344 3.7 4.3
AGE >17 W/O CC.
91.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .7937 3.8 4.7
AGE 0-17.
92.............. 04 MED INTERSTITIAL LUNG DISEASE W 1.2296 5.6 6.8
CC.
93.............. 04 MED INTERSTITIAL LUNG DISEASE W/ .7443 3.5 4.3
O CC.
94.............. 04 MED PNEUMOTHORAX W CC.......... 1.2024 5.4 6.9
95.............. 04 MED PNEUMOTHORAX W/O CC........ .5817 3.2 3.9
96.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .7604 4.1 4.9
W CC.
97.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .5636 3.2 3.8
W/O CC.
98.............. 04 MED BRONCHITIS & ASTHMA AGE 0- .7496 3.1 4.6
17.
99.............. 04 MED RESPIRATORY SIGNS & .6964 2.6 3.3
SYMPTOMS W CC.
100............. 04 MED RESPIRATORY SIGNS & .5186 1.8 2.2
SYMPTOMS W/O CC.
101............. 04 MED OTHER RESPIRATORY SYSTEM .8604 3.6 4.7
DIAGNOSES W CC.
102............. 04 MED OTHER RESPIRATORY SYSTEM .5207 2.1 2.7
DIAGNOSES W/O CC.
103............. PRE SURG HEART TRANSPLANT........... 20.2413 39.2 58.5
[[Page 40056]]
104............. 05 SURG CARDIAC VALVE & OTH MAJOR 7.8411 13.2 15.3
CARDIOTHORACIC PROC W CARD
CATH.
105............. 05 SURG CARDIAC VALVE & OTH MAJOR 5.6796 8.8 10.4
CARDIOTHORACIC PROC W/O
CARD CATH.
106............. 05 SURG CORONARY BYPASS W PTCA..... 7.4396 10.7 12.3
107............. 05 SURG CORONARY BYPASS W CARDIAC 5.3125 9.7 10.9
CATH.
108............. 05 SURG OTHER CARDIOTHORACIC 5.5325 9.2 11.2
PROCEDURES.
109............. 05 SURG CORONARY BYPASS W/O PTCA OR 3.9017 7.0 8.0
CARDIAC CATH.
110............. 05 SURG MAJOR CARDIOVASCULAR 4.1576 8.1 10.3
PROCEDURES W CC.
111............. 05 SURG MAJOR CARDIOVASCULAR 2.2865 4.3 5.1
PROCEDURES W/O CC.
112............. 05 SURG NO LONGER VALID............ .0000 .0 .0
113............. 05 SURG AMPUTATION FOR CIRC SYSTEM 2.6714 9.8 12.9
DISORDERS EXCEPT UPPER
LIMB & TOE.
114............. 05 SURG UPPER LIMB & TOE AMPUTATION 1.6809 7.3 9.4
FOR CIRC SYSTEM DISORDERS.
115............. 05 SURG PRM CARD PACEM IMPL W 3.3822 7.2 9.2
AMI,HRT FAIL OR SHK,OR
AICD LEAD OR GN.
116............. 05 SURG OTHER PERMANENT CARDIAC 2.2648 3.6 4.9
PACEMAKER IMPLANT.
117............. 05 SURG CARDIAC PACEMAKER REVISION 1.3351 2.8 4.5
EXCEPT DEVICE REPLACEMENT.
118............. 05 SURG CARDIAC PACEMAKER DEVICE 1.4339 1.8 2.7
REPLACEMENT.
119............. 05 SURG VEIN LIGATION & STRIPPING.. 1.3578 3.3 5.3
120............. 05 SURG OTHER CIRCULATORY SYSTEM 2.3552 6.7 9.9
O.R. PROCEDURES.
121............. 05 MED CIRCULATORY DISORDERS W AMI 1.5787 5.6 6.9
& MAJOR COMP, DISCHARGED
ALIVE.
122............. 05 MED CIRCULATORY DISORDERS W AMI 1.0241 3.2 3.9
W/O MAJOR COMP, DISCHARGED
ALIVE.
123............. 05 MED CIRCULATORY DISORDERS W 1.5883 3.2 5.0
AMI, EXPIRED.
124............. 05 MED CIRCULATORY DISORDERS 1.4072 3.6 4.6
EXCEPT AMI, W CARD CATH &
COMPLEX DIAG.
125............. 05 MED CIRCULATORY DISORDERS 1.0406 2.2 2.8
EXCEPT AMI, W CARD CATH W/
O COMPLEX DIAG.
126............. 05 MED ACUTE & SUBACUTE 2.6836 10.5 13.0
ENDOCARDITIS.
127............. 05 MED HEART FAILURE & SHOCK...... 1.0103 4.5 5.6
128............. 05 MED DEEP VEIN THROMBOPHLEBITIS. .7320 5.2 5.9
129............. 05 MED CARDIAC ARREST, UNEXPLAINED 1.0209 1.7 2.8
130............. 05 MED PERIPHERAL VASCULAR .9379 5.0 6.1
DISORDERS W CC.
131............. 05 MED PERIPHERAL VASCULAR .5725 3.8 4.5
DISORDERS W/O CC.
132............. 05 MED ATHEROSCLEROSIS W CC....... .6473 2.5 3.1
133............. 05 MED ATHEROSCLEROSIS W/O CC..... .5558 1.9 2.3
134............. 05 MED HYPERTENSION............... .5814 2.7 3.4
135............. 05 MED CARDIAC CONGENITAL & .9128 3.7 4.8
VALVULAR DISORDERS AGE >17
W CC.
136............. 05 MED CARDIAC CONGENITAL & .5643 2.2 2.8
VALVULAR DISORDERS AGE >17
W/O CC.
137............. 05 MED *CARDIAC CONGENITAL & .8177 3.3 3.3
VALVULAR DISORDERS AGE 0-
17.
138............. 05 MED CARDIAC ARRHYTHMIA & .8222 3.3 4.2
CONDUCTION DISORDERS W CC.
139............. 05 MED CARDIAC ARRHYTHMIA & .4961 2.1 2.5
CONDUCTION DISORDERS W/O
CC.
140............. 05 MED ANGINA PECTORIS............ .5335 2.2 2.7
141............. 05 MED SYNCOPE & COLLAPSE W CC.... .7241 3.0 3.8
142............. 05 MED SYNCOPE & COLLAPSE W/O CC.. .5395 2.2 2.7
143............. 05 MED CHEST PAIN................. .5191 1.7 2.1
144............. 05 MED OTHER CIRCULATORY SYSTEM 1.2015 4.3 5.8
DIAGNOSES W CC.
145............. 05 MED OTHER CIRCULATORY SYSTEM .5899 2.2 2.8
DIAGNOSES W/O CC.
146............. 06 SURG RECTAL RESECTION W CC...... 2.7764 9.6 10.9
147............. 06 SURG RECTAL RESECTION W/O CC.... 1.5993 6.2 6.7
148............. 06 SURG MAJOR SMALL & LARGE BOWEL 3.5332 11.1 13.1
PROCEDURES W CC.
149............. 06 SURG MAJOR SMALL & LARGE BOWEL 1.5063 6.2 6.7
PROCEDURES W/O CC.
150............. 06 SURG PERITONEAL ADHESIOLYSIS W 2.9483 10.5 12.2
CC.
151............. 06 SURG PERITONEAL ADHESIOLYSIS W/O 1.3451 5.3 6.3
CC.
152............. 06 SURG MINOR SMALL & LARGE BOWEL 1.9477 7.4 8.7
PROCEDURES W CC.
153............. 06 SURG MINOR SMALL & LARGE BOWEL 1.1642 5.1 5.6
PROCEDURES W/O CC.
154............. 06 SURG STOMACH, ESOPHAGEAL & 4.3519 11.9 14.7
DUODENAL PROCEDURES AGE
>17 W CC.
155............. 06 SURG STOMACH, ESOPHAGEAL & 1.3273 3.4 4.5
DUODENAL PROCEDURES AGE
>17 W/O CC.
156............. 06 SURG *STOMACH, ESOPHAGEAL & .8421 6.0 6.0
DUODENAL PROCEDURES AGE 0-
17.
157............. 06 SURG ANAL & STOMAL PROCEDURES W 1.2599 4.4 5.9
CC.
158............. 06 SURG ANAL & STOMAL PROCEDURES W/ .6209 2.0 2.5
O CC.
[[Page 40057]]
159............. 06 SURG HERNIA PROCEDURES EXCEPT 1.3618 4.2 5.4
INGUINAL & FEMORAL AGE >17
W CC.
160............. 06 SURG HERNIA PROCEDURES EXCEPT .7655 2.2 2.7
INGUINAL & FEMORAL AGE >17
W/O CC.
161............. 06 SURG INGUINAL & FEMORAL HERNIA 1.1375 3.2 4.5
PROCEDURES AGE >17 W CC.
162............. 06 SURG INGUINAL & FEMORAL HERNIA .6121 1.6 1.9
PROCEDURES AGE >17 W/O CC.
163............. 06 SURG *HERNIA PROCEDURES AGE 0-17 .6909 2.1 2.1
164............. 06 SURG APPENDECTOMY W COMPLICATED 2.3960 7.8 9.0
PRINCIPAL DIAG W CC.
165............. 06 SURG APPENDECTOMY W COMPLICATED 1.2904 4.5 5.0
PRINCIPAL DIAG W/O CC.
166............. 06 SURG APPENDECTOMY W/O 1.4934 4.2 5.4
COMPLICATED PRINCIPAL DIAG
W CC.
167............. 06 SURG APPENDECTOMY W/O .8753 2.2 2.6
COMPLICATED PRINCIPAL DIAG
W/O CC.
168............. 03 SURG MOUTH PROCEDURES W CC...... 1.2982 3.6 5.2
169............. 03 SURG MOUTH PROCEDURES W/O CC.... .6964 1.8 2.3
170............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 3.0540 9.4 12.5
PROCEDURES W CC.
171............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 1.1716 3.8 4.8
PROCEDURES W/O CC.
172............. 06 MED DIGESTIVE MALIGNANCY W CC.. 1.3985 5.9 7.6
173............. 06 MED DIGESTIVE MALIGNANCY W/O CC .6933 3.0 3.9
174............. 06 MED G.I. HEMORRHAGE W CC....... .9896 4.1 5.1
175............. 06 MED G.I. HEMORRHAGE W/O CC..... .5419 2.6 3.0
176............. 06 MED COMPLICATED PEPTIC ULCER... 1.0888 4.4 5.6
177............. 06 MED UNCOMPLICATED PEPTIC ULCER .8910 3.9 4.8
W CC.
178............. 06 MED UNCOMPLICATED PEPTIC ULCER .6408 2.7 3.2
W/O CC.
179............. 06 MED INFLAMMATORY BOWEL DISEASE. 1.0868 5.1 6.4
180............. 06 MED G.I. OBSTRUCTION W CC...... .9565 4.6 5.7
181............. 06 MED G.I. OBSTRUCTION W/O CC.... .5237 3.0 3.5
182............. 06 MED ESOPHAGITIS, GASTROENT & .7940 3.6 4.6
MISC DIGEST DISORDERS AGE
>17 W CC.
183............. 06 MED ESOPHAGITIS, GASTROENT & .5568 2.4 3.0
MISC DIGEST DISORDERS AGE
>17 W/O CC.
184............. 06 MED ESOPHAGITIS, GASTROENT & .4141 2.5 3.0
MISC DIGEST DISORDERS AGE
0-17.
185............. 03 MED DENTAL & ORAL DIS EXCEPT .8660 3.6 4.8
EXTRACTIONS &
RESTORATIONS, AGE >17.
186............. 03 MED *DENTAL & ORAL DIS EXCEPT .3210 2.9 2.9
EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187............. 03 MED DENTAL EXTRACTIONS & .7868 3.2 4.2
RESTORATIONS.
188............. 06 MED OTHER DIGESTIVE SYSTEM 1.1250 4.6 6.0
DIAGNOSES AGE >17 W CC.
189............. 06 MED OTHER DIGESTIVE SYSTEM .5776 2.5 3.3
DIAGNOSES AGE >17 W/O CC.
190............. 06 MED OTHER DIGESTIVE SYSTEM 1.1897 4.5 7.4
DIAGNOSES AGE 0-17.
191............. 07 SURG PANCREAS, LIVER & SHUNT 4.6199 12.2 15.5
PROCEDURES W CC.
192............. 07 SURG PANCREAS, LIVER & SHUNT 1.8255 6.0 7.1
PROCEDURES W/O CC.
193............. 07 SURG BILIARY TRACT PROC EXCEPT 3.5085 11.6 13.6
ONLY CHOLECYST W OR W/O
C.D.E. W CC.
194............. 07 SURG BILIARY TRACT PROC EXCEPT 1.7294 6.3 7.3
ONLY CHOLECYST W OR W/O
C.D.E. W/O CC.
195............. 07 SURG CHOLECYSTECTOMY W C.D.E. W 3.0863 9.4 10.9
CC.
196............. 07 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6111 5.3 6.0
O CC.
197............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.5748 8.1 9.6
LAPAROSCOPE W/O C.D.E. W
CC.
198............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.2062 4.2 4.7
LAPAROSCOPE W/O C.D.E. W/O
CC.
199............. 07 SURG HEPATOBILIARY DIAGNOSTIC 2.5070 8.4 10.9
PROCEDURE FOR MALIGNANCY.
200............. 07 SURG HEPATOBILIARY DIAGNOSTIC 3.1811 8.5 12.0
PROCEDURE FOR NON-
MALIGNANCY.
201............. 07 SURG OTHER HEPATOBILIARY OR 3.7986 12.3 15.6
PANCREAS O.R. PROCEDURES.
202............. 07 MED CIRRHOSIS & ALCOHOLIC 1.3291 5.5 7.0
HEPATITIS.
203............. 07 MED MALIGNANCY OF HEPATOBILIARY 1.3627 5.7 7.3
SYSTEM OR PANCREAS.
204............. 07 MED DISORDERS OF PANCREAS 1.2047 4.9 6.2
EXCEPT MALIGNANCY.
205............. 07 MED DISORDERS OF LIVER EXCEPT 1.2207 5.2 6.7
MALIG,CIRR,ALC HEPA W CC.
206............. 07 MED DISORDERS OF LIVER EXCEPT .7302 3.2 4.1
MALIG,CIRR,ALC HEPA W/O CC.
207............. 07 MED DISORDERS OF THE BILIARY 1.1120 4.3 5.5
TRACT W CC.
208............. 07 MED DISORDERS OF THE BILIARY .6380 2.4 3.0
TRACT W/O CC.
209............. 08 SURG MAJOR JOINT & LIMB 1.9917 4.6 5.1
REATTACHMENT PROCEDURES OF
LOWER EXTREMITY.
210............. 08 SURG HIP & FEMUR PROCEDURES 1.7503 6.1 6.9
EXCEPT MAJOR JOINT AGE >17
W CC.
[[Page 40058]]
211............. 08 SURG HIP & FEMUR PROCEDURES 1.2236 4.6 5.0
EXCEPT MAJOR JOINT AGE >17
W/O CC.
212............. 08 SURG *HIP & FEMUR PROCEDURES .8457 11.1 11.1
EXCEPT MAJOR JOINT AGE 0-
17.
213............. 08 SURG AMPUTATION FOR 1.9437 7.7 10.0
MUSCULOSKELETAL SYSTEM &
CONN TISSUE DISORDERS.
214............. 08 SURG NO LONGER VALID............ .0000 .0 .0
215............. 08 SURG NO LONGER VALID............ .0000 .0 .0
216............. 08 SURG BIOPSIES OF MUSCULOSKELETAL 2.3172 8.5 10.9
SYSTEM & CONNECTIVE TISSUE.
217............. 08 SURG WND DEBRID & SKN GRFT 3.2005 11.0 15.2
EXCEPT HAND,FOR MUSCSKELET
& CONN TISS DIS.
218............. 08 SURG LOWER EXTREM & HUMER PROC 1.5499 4.7 5.8
EXCEPT HIP,FOOT,FEMUR AGE
>17 W CC.
219............. 08 SURG LOWER EXTREM & HUMER PROC .9950 2.8 3.3
EXCEPT HIP,FOOT,FEMUR AGE
>17 W/O CC.
220............. 08 SURG *LOWER EXTREM & HUMER PROC .5834 5.3 5.3
EXCEPT HIP,FOOT,FEMUR AGE
0-17.
221............. 08 SURG NO LONGER VALID............ .0000 .0 .0
222............. 08 SURG NO LONGER VALID............ .0000 .0 .0
223............. 08 SURG MAJOR SHOULDER/ELBOW PROC, .9723 2.1 2.9
OR OTHER UPPER EXTREMITY
PROC W CC.
224............. 08 SURG SHOULDER,ELBOW OR FOREARM .7697 1.6 1.9
PROC,EXC MAJOR JOINT PROC,
W/O CC.
225............. 08 SURG FOOT PROCEDURES............ 1.1164 3.8 5.3
226............. 08 SURG SOFT TISSUE PROCEDURES W CC 1.5902 5.2 7.3
227............. 08 SURG SOFT TISSUE PROCEDURES W/O .7922 2.1 2.7
CC.
228............. 08 SURG MAJOR THUMB OR JOINT 1.0906 2.7 4.0
PROC,OR OTH HAND OR WRIST
PROC W CC.
229............. 08 SURG HAND OR WRIST PROC, EXCEPT .7142 1.9 2.5
MAJOR JOINT PROC, W/O CC.
230............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.3598 3.9 5.8
INT FIX DEVICES OF HIP &
FEMUR.
231............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.4340 3.6 5.4
INT FIX DEVICES EXCEPT HIP
& FEMUR.
232............. 08 SURG ARTHROSCOPY................ .9532 1.8 2.9
233............. 08 SURG OTHER MUSCULOSKELET SYS & 2.0945 6.3 8.4
CONN TISS O.R. PROC W CC.
234............. 08 SURG OTHER MUSCULOSKELET SYS & 1.2097 2.7 3.6
CONN TISS O.R. PROC W/O CC.
235............. 08 MED FRACTURES OF FEMUR......... .7632 4.1 5.5
236............. 08 MED FRACTURES OF HIP & PELVIS.. .6889 3.9 4.9
237............. 08 MED SPRAINS, STRAINS, & .5325 3.0 3.6
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238............. 08 MED OSTEOMYELITIS.............. 1.4154 7.4 9.4
239............. 08 MED PATHOLOGICAL FRACTURES & 1.0032 5.4 6.7
MUSCULOSKELETAL & CONN
TISS MALIGNANCY.
240............. 08 MED CONNECTIVE TISSUE DISORDERS 1.3692 5.6 7.3
W CC.
241............. 08 MED CONNECTIVE TISSUE DISORDERS .6315 3.3 4.0
W/O CC.
242............. 08 MED SEPTIC ARTHRITIS........... 1.0953 5.7 7.2
243............. 08 MED MEDICAL BACK PROBLEMS...... .7304 4.0 4.9
244............. 08 MED BONE DISEASES & SPECIFIC .7152 4.1 5.1
ARTHROPATHIES W CC.
245............. 08 MED BONE DISEASES & SPECIFIC .4665 2.9 3.6
ARTHROPATHIES W/O CC.
246............. 08 MED NON-SPECIFIC ARTHROPATHIES. .5717 3.2 4.1
247............. 08 MED SIGNS & SYMPTOMS OF .5587 2.8 3.6
MUSCULOSKELETAL SYSTEM &
CONN TISSUE.
248............. 08 MED TENDONITIS, MYOSITIS & .8160 4.1 5.1
BURSITIS.
249............. 08 MED AFTERCARE, MUSCULOSKELETAL .6784 2.7 3.9
SYSTEM & CONNECTIVE TISSUE.
250............. 08 MED FX, SPRN, STRN & DISL OF .6809 3.5 4.3
FOREARM, HAND, FOOT AGE
>17 W CC.
251............. 08 MED FX, SPRN, STRN & DISL OF .4582 2.4 2.9
FOREARM, HAND, FOOT AGE
>17 W/O CC.
252............. 08 MED *FX, SPRN, STRN & DISL OF .2533 1.8 1.8
FOREARM, HAND, FOOT AGE 0-
17.
253............. 08 MED FX, SPRN, STRN & DISL OF .7397 4.0 5.0
UPARM,LOWLEG EX FOOT AGE
>17 W CC.
254............. 08 MED FX, SPRN, STRN & DISL OF .4294 2.8 3.3
UPARM,LOWLEG EX FOOT AGE
>17 W/O CC.
255............. 08 MED *FX, SPRN, STRN & DISL OF .2951 2.9 2.9
UPARM,LOWLEG EX FOOT AGE 0-
17.
256............. 08 MED OTHER MUSCULOSKELETAL .8152 4.2 5.4
SYSTEM & CONNECTIVE TISSUE
DIAGNOSES.
[[Page 40059]]
257............. 09 SURG TOTAL MASTECTOMY FOR .8783 2.2 2.8
MALIGNANCY W CC.
258............. 09 SURG TOTAL MASTECTOMY FOR .6954 1.7 1.9
MALIGNANCY W/O CC.
259............. 09 SURG SUBTOTAL MASTECTOMY FOR .8763 1.8 2.7
MALIGNANCY W CC.
260............. 09 SURG SUBTOTAL MASTECTOMY FOR .6435 1.3 1.4
MALIGNANCY W/O CC.
261............. 09 SURG BREAST PROC FOR NON- .9240 1.7 2.3
MALIGNANCY EXCEPT BIOPSY &
LOCAL EXCISION.
262............. 09 SURG BREAST BIOPSY & LOCAL .8487 3.0 4.3
EXCISION FOR NON-
MALIGNANCY.
263............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 2.0570 9.1 12.3
SKN ULCER OR CELLULITIS W
CC.
264............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 1.1079 5.6 7.3
SKN ULCER OR CELLULITIS W/
O CC.
265............. 09 SURG SKIN GRAFT &/OR DEBRID 1.6795 5.2 7.6
EXCEPT FOR SKIN ULCER OR
CELLULITIS W CC.
266............. 09 SURG SKIN GRAFT &/OR DEBRID .8414 2.4 3.4
EXCEPT FOR SKIN ULCER OR
CELLULITIS W/O CC.
267............. 09 SURG PERIANAL & PILONIDAL .9406 3.3 4.5
PROCEDURES.
268............. 09 SURG SKIN, SUBCUTANEOUS TISSUE & 1.2368 2.5 3.7
BREAST PLASTIC PROCEDURES.
269............. 09 SURG OTHER SKIN, SUBCUT TISS & 1.7731 6.9 9.2
BREAST PROC W CC.
270............. 09 SURG OTHER SKIN, SUBCUT TISS & .7806 2.5 3.6
BREAST PROC W/O CC.
271............. 09 MED SKIN ULCERS................ 1.0365 6.2 7.7
272............. 09 MED MAJOR SKIN DISORDERS W CC.. 1.0248 5.2 6.7
273............. 09 MED MAJOR SKIN DISORDERS W/O CC .5638 3.4 4.2
274............. 09 MED MALIGNANT BREAST DISORDERS 1.1927 5.5 7.3
W CC.
275............. 09 MED MALIGNANT BREAST DISORDERS .6647 3.1 4.6
W/O CC.
276............. 09 MED NON-MALIGANT BREAST .7033 4.0 5.0
DISORDERS.
277............. 09 MED CELLULITIS AGE >17 W CC.... .8534 5.1 6.1
278............. 09 MED CELLULITIS AGE >17 W/O CC.. .5487 3.8 4.5
279............. 09 MED *CELLULITIS AGE 0-17....... .6632 4.2 4.2
280............. 09 MED TRAUMA TO THE SKIN, SUBCUT .6941 3.5 4.4
TISS & BREAST AGE >17 W CC.
281............. 09 MED TRAUMA TO THE SKIN, SUBCUT .4593 2.5 3.1
TISS & BREAST AGE >17 W/O
CC.
282............. 09 MED *TRAUMA TO THE SKIN, SUBCUT .2565 2.2 2.2
TISS & BREAST AGE 0-17.
283............. 09 MED MINOR SKIN DISORDERS W CC.. .7152 3.8 4.9
284............. 09 MED MINOR SKIN DISORDERS W/O CC .4204 2.5 3.2
285............. 10 SURG AMPUTAT OF LOWER LIMB FOR 2.1297 9.1 11.4
ENDOCRINE,NUTRIT,& METABOL
DISORDERS.
286............. 10 SURG ADRENAL & PITUITARY 2.2343 5.3 6.9
PROCEDURES.
287............. 10 SURG SKIN GRAFTS & WOUND DEBRID 1.9569 8.9 11.7
FOR ENDOC, NUTRIT & METAB
DISORDERS.
288............. 10 SURG O.R. PROCEDURES FOR OBESITY 2.1590 4.9 6.0
289............. 10 SURG PARATHYROID PROCEDURES..... .9573 1.9 3.0
290............. 10 SURG THYROID PROCEDURES......... .8862 1.7 2.3
291............. 10 SURG THYROGLOSSAL PROCEDURES.... .5964 1.5 1.8
292............. 10 SURG OTHER ENDOCRINE, NUTRIT & 2.6892 8.8 11.6
METAB O.R. PROC W CC.
293............. 10 SURG OTHER ENDOCRINE, NUTRIT & 1.3059 4.3 5.9
METAB O.R. PROC W/O CC.
294............. 10 MED DIABETES AGE >35........... .7608 3.8 4.9
295............. 10 MED DIABETES AGE 0-35.......... .7457 3.1 3.9
296............. 10 MED NUTRITIONAL & MISC .8615 4.3 5.5
METABOLIC DISORDERS AGE
>17 W CC.
297............. 10 MED NUTRITIONAL & MISC .5047 2.9 3.5
METABOLIC DISORDERS AGE
>17 W/O CC.
298............. 10 MED NUTRITIONAL & MISC .4155 2.3 3.0
METABOLIC DISORDERS AGE 0-
17.
299............. 10 MED INBORN ERRORS OF METABOLISM .9223 4.4 5.7
300............. 10 MED ENDOCRINE DISORDERS W CC... 1.1243 5.3 6.6
301............. 10 MED ENDOCRINE DISORDERS W/O CC. .6078 3.0 3.8
302............. 11 SURG KIDNEY TRANSPLANT.......... 3.3278 7.9 9.3
303............. 11 SURG KIDNEY,URETER & MAJOR 2.4884 7.5 9.0
BLADDER PROCEDURES FOR
NEOPLASM.
304............. 11 SURG KIDNEY,URETER & MAJOR 2.4618 7.4 9.7
BLADDER PROC FOR NON-NEOPL
W CC.
305............. 11 SURG KIDNEY,URETER & MAJOR 1.1502 3.1 3.8
BLADDER PROC FOR NON-NEOPL
W/O CC.
306............. 11 SURG PROSTATECTOMY W CC......... 1.2988 4.3 6.2
307............. 11 SURG PROSTATECTOMY W/O CC....... .6050 1.9 2.2
308............. 11 SURG MINOR BLADDER PROCEDURES W 1.6896 4.8 6.9
CC.
309............. 11 SURG MINOR BLADDER PROCEDURES W/ .8936 1.8 2.3
O CC.
310............. 11 SURG TRANSURETHRAL PROCEDURES W 1.1366 3.3 4.7
CC.
311............. 11 SURG TRANSURETHRAL PROCEDURES W/ .5957 1.5 1.8
O CC.
312............. 11 SURG URETHRAL PROCEDURES, AGE 1.0782 3.3 4.8
>17 W CC.
313............. 11 SURG URETHRAL PROCEDURES, AGE .6584 1.8 2.3
>17 W/O CC.
[[Page 40060]]
314............. 11 SURG *URETHRAL PROCEDURES, AGE 0- .4944 2.3 2.3
17.
315............. 11 SURG OTHER KIDNEY & URINARY 2.1550 4.8 8.3
TRACT O.R. PROCEDURES.
316............. 11 MED RENAL FAILURE.............. 1.3745 5.6 7.3
317............. 11 MED ADMIT FOR RENAL DIALYSIS... .6130 2.0 2.9
318............. 11 MED KIDNEY & URINARY TRACT 1.1723 5.1 6.6
NEOPLASMS W CC.
319............. 11 MED KIDNEY & URINARY TRACT .5852 2.1 2.8
NEOPLASMS W/O CC.
320............. 11 MED KIDNEY & URINARY TRACT .8593 4.6 5.6
INFECTIONS AGE >17 W CC.
321............. 11 MED KIDNEY & URINARY TRACT .5560 3.3 3.9
INFECTIONS AGE >17 W/O CC.
322............. 11 MED KIDNEY & URINARY TRACT .5267 3.6 4.3
INFECTIONS AGE 0-17.
323............. 11 MED URINARY STONES W CC, &/OR .7970 2.5 3.3
ESW LITHOTRIPSY.
324............. 11 MED URINARY STONES W/O CC...... .4422 1.6 1.9
325............. 11 MED KIDNEY & URINARY TRACT .6336 3.1 4.0
SIGNS & SYMPTOMS AGE >17 W
CC.
326............. 11 MED KIDNEY & URINARY TRACT .4120 2.1 2.7
SIGNS & SYMPTOMS AGE >17 W/
O CC.
327............. 11 MED KIDNEY & URINARY TRACT .3697 2.8 3.2
SIGNS & SYMPTOMS AGE 0-17.
328............. 11 MED URETHRAL STRICTURE AGE >17 .7268 2.9 3.9
W CC.
329............. 11 MED URETHRAL STRICTURE AGE >17 .4458 1.6 2.0
W/O CC.
330............. 11 MED *URETHRAL STRICTURE AGE 0- .3185 1.6 1.6
17.
331............. 11 MED OTHER KIDNEY & URINARY 1.0640 4.6 6.0
TRACT DIAGNOSES AGE >17 W
CC.
332............. 11 MED OTHER KIDNEY & URINARY .6056 2.6 3.4
TRACT DIAGNOSES AGE >17 W/
O CC.
333............. 11 MED OTHER KIDNEY & URINARY .7907 3.9 5.3
TRACT DIAGNOSES AGE 0-17.
334............. 12 SURG MAJOR MALE PELVIC 1.5177 4.3 5.0
PROCEDURES W CC.
335............. 12 SURG MAJOR MALE PELVIC 1.1047 3.1 3.3
PROCEDURES W/O CC.
336............. 12 SURG TRANSURETHRAL PROSTATECTOMY .8630 2.8 3.6
W CC.
337............. 12 SURG TRANSURETHRAL PROSTATECTOMY .5861 1.9 2.1
W/O CC.
338............. 12 SURG TESTES PROCEDURES, FOR 1.2191 3.7 5.6
MALIGNANCY.
339............. 12 SURG TESTES PROCEDURES, NON- 1.1555 3.3 5.0
MALIGNANCY AGE >17.
340............. 12 SURG *TESTES PROCEDURES, NON- .2830 2.4 2.4
MALIGNANCY AGE 0-17.
341............. 12 SURG PENIS PROCEDURES........... 1.1306 2.0 3.0
342............. 12 SURG CIRCUMCISION AGE >17....... .7852 2.5 3.3
343............. 12 SURG *CIRCUMCISION AGE 0-17..... .1538 1.7 1.7
344............. 12 SURG OTHER MALE REPRODUCTIVE 1.1741 1.6 2.4
SYSTEM O.R. PROCEDURES FOR
MALIGNANCY.
345............. 12 SURG OTHER MALE REPRODUCTIVE .9149 2.7 4.0
SYSTEM O.R. PROC EXCEPT
FOR MALIGNANCY.
346............. 12 MED MALIGNANCY, MALE 1.0304 4.9 6.4
REPRODUCTIVE SYSTEM, W CC.
347............. 12 MED MALIGNANCY, MALE .5660 2.3 3.0
REPRODUCTIVE SYSTEM, W/O
CC.
348............. 12 MED BENIGN PROSTATIC .6998 3.4 4.4
HYPERTROPHY W CC.
349............. 12 MED BENIGN PROSTATIC .4128 2.0 2.5
HYPERTROPHY W/O CC.
350............. 12 MED INFLAMMATION OF THE MALE .7164 3.8 4.6
REPRODUCTIVE SYSTEM.
351............. 12 MED *STERILIZATION, MALE....... .2360 1.3 1.3
352............. 12 MED OTHER MALE REPRODUCTIVE .6868 3.0 4.2
SYSTEM DIAGNOSES.
353............. 13 SURG PELVIC EVISCERATION, 1.8493 5.4 6.8
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354............. 13 SURG UTERINE,ADNEXA PROC FOR NON- 1.5317 5.1 6.1
OVARIAN/ADNEXAL MALIG W CC.
355............. 13 SURG UTERINE,ADNEXA PROC FOR NON- .9033 3.1 3.3
OVARIAN/ADNEXAL MALIG W/O
CC.
356............. 13 SURG FEMALE REPRODUCTIVE SYSTEM .7440 2.0 2.3
RECONSTRUCTIVE PROCEDURES.
357............. 13 SURG UTERINE & ADNEXA PROC FOR 2.4380 7.5 9.2
OVARIAN OR ADNEXAL
MALIGNANCY.
358............. 13 SURG UTERINE & ADNEXA PROC FOR 1.1902 3.7 4.4
NON-MALIGNANCY W CC.
359............. 13 SURG UTERINE & ADNEXA PROC FOR .8165 2.6 2.8
NON-MALIGNANCY W/O CC.
360............. 13 SURG VAGINA, CERVIX & VULVA .8520 2.4 2.9
PROCEDURES.
361............. 13 SURG LAPAROSCOPY & INCISIONAL 1.0964 2.1 3.0
TUBAL INTERRUPTION.
362............. 13 SURG *ENDOSCOPIC TUBAL .3017 1.4 1.4
INTERRUPTION.
363............. 13 SURG D&C, CONIZATION & RADIO- .8158 2.6 3.6
IMPLANT, FOR MALIGNANCY.
364............. 13 SURG D&C, CONIZATION EXCEPT FOR .8170 2.9 4.1
MALIGNANCY.
365............. 13 SURG OTHER FEMALE REPRODUCTIVE 2.0008 5.8 8.1
SYSTEM O.R. PROCEDURES.
366............. 13 MED MALIGNANCY, FEMALE 1.2699 5.6 7.4
REPRODUCTIVE SYSTEM W CC.
367............. 13 MED MALIGNANCY, FEMALE .5767 2.4 3.2
REPRODUCTIVE SYSTEM W/O CC.
368............. 13 MED INFECTIONS, FEMALE 1.1355 5.6 7.0
REPRODUCTIVE SYSTEM.
369............. 13 MED MENSTRUAL & OTHER FEMALE .5581 2.5 3.4
REPRODUCTIVE SYSTEM
DISORDERS.
370............. 14 SURG CESAREAN SECTION W CC...... 1.0572 4.7 6.1
371............. 14 SURG CESAREAN SECTION W/O CC.... .6845 3.3 3.7
[[Page 40061]]
372............. 14 MED VAGINAL DELIVERY W .5550 2.7 3.3
COMPLICATING DIAGNOSES.
373............. 14 MED VAGINAL DELIVERY W/O .3774 2.0 2.3
COMPLICATING DIAGNOSES.
374............. 14 SURG VAGINAL DELIVERY W .6835 2.5 3.1
STERILIZATION &/OR D&C.
375............. 14 SURG VAGINAL DELIVERY W O.R. .5759 2.1 2.3
PROC EXCEPT STERIL &/OR
D&C.
376............. 14 MED POSTPARTUM & POST ABORTION .4963 2.5 3.2
DIAGNOSES W/O O.R.
PROCEDURE.
377............. 14 SURG POSTPARTUM & POST ABORTION 1.6892 3.8 5.6
DIAGNOSES W O.R. PROCEDURE.
378............. 14 MED ECTOPIC PREGNANCY.......... .8017 2.0 2.4
379............. 14 MED THREATENED ABORTION........ .4521 2.4 3.6
380............. 14 MED ABORTION W/O D&C........... .4201 1.6 2.1
381............. 14 SURG ABORTION W D&C, ASPIRATION .6628 1.8 2.5
CURETTAGE OR HYSTEROTOMY.
382............. 14 MED FALSE LABOR................ .1599 1.2 1.3
383............. 14 MED OTHER ANTEPARTUM DIAGNOSES .4915 2.8 3.8
W MEDICAL COMPLICATIONS.
384............. 14 MED OTHER ANTEPARTUM DIAGNOSES .3626 1.6 2.1
W/O MEDICAL COMPLICATIONS.
385............. 15 MED *NEONATES, DIED OR 1.3743 1.8 1.8
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386............. 15 MED *EXTREME IMMATURITY OR 4.5319 17.9 17.9
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387............. 15 MED *PREMATURITY W MAJOR 3.0952 13.3 13.3
PROBLEMS.
388............. 15 MED *PREMATURITY W/O MAJOR 1.8676 8.6 8.6
PROBLEMS.
389............. 15 MED FULL TERM NEONATE W MAJOR 3.1794 9.3 16.0
PROBLEMS.
390............. 15 MED NEONATE W OTHER SIGNIFICANT 1.1253 3.5 4.3
PROBLEMS.
391............. 15 MED *NORMAL NEWBORN............ .1524 3.1 3.1
392............. 16 SURG SPLENECTOMY AGE >17........ 3.3892 8.3 10.8
393............. 16 SURG *SPLENECTOMY AGE 0-17...... 1.3462 9.1 9.1
394............. 16 SURG OTHER O.R. PROCEDURES OF 1.8231 5.1 8.1
THE BLOOD AND BLOOD
FORMING ORGANS.
395............. 16 MED RED BLOOD CELL DISORDERS .8192 3.5 4.7
AGE >17.
396............. 16 MED RED BLOOD CELL DISORDERS 1.0407 3.9 5.0
AGE 0-17.
397............. 16 MED COAGULATION DISORDERS...... 1.2671 4.2 5.6
398............. 16 MED RETICULOENDOTHELIAL & 1.3082 5.1 6.4
IMMUNITY DISORDERS W CC.
399............. 16 MED RETICULOENDOTHELIAL & .6675 3.0 3.7
IMMUNITY DISORDERS W/O CC.
400............. 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 2.9346 7.4 10.5
O.R. PROCEDURE.
401............. 17 SURG LYMPHOMA & NON-ACUTE 2.9905 9.9 12.8
LEUKEMIA W OTHER O.R. PROC
W CC.
402............. 17 SURG LYMPHOMA & NON-ACUTE 1.1594 3.1 4.4
LEUKEMIA W OTHER O.R. PROC
W/O CC.
403............. 17 MED LYMPHOMA & NON-ACUTE 1.8579 6.8 9.1
LEUKEMIA W CC.
404............. 17 MED LYMPHOMA & NON-ACUTE .8718 3.4 4.6
LEUKEMIA W/O CC.
405............. 17 MED *ACUTE LEUKEMIA W/O MAJOR 1.9086 4.9 4.9
O.R. PROCEDURE AGE 0-17.
406............. 17 SURG MYELOPROLIF DISORD OR 2.9939 8.4 11.1
POORLY DIFF NEOPL W MAJ
O.R.PROC W CC.
407............. 17 SURG MYELOPROLIF DISORD OR 1.2426 3.8 4.7
POORLY DIFF NEOPL W MAJ
O.R.PROC W/O CC.
408............. 17 SURG MYELOPROLIF DISORD OR 2.2144 6.0 9.2
POORLY DIFF NEOPL W OTHER
O.R.PROC.
409............. 17 MED RADIOTHERAPY............... 1.1575 4.9 6.3
410............. 17 MED CHEMOTHERAPY W/O ACUTE .9991 3.3 4.1
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411............. 17 MED HISTORY OF MALIGNANCY W/O .4481 1.8 2.3
ENDOSCOPY.
412............. 17 MED HISTORY OF MALIGNANCY W .5958 1.9 2.4
ENDOSCOPY.
413............. 17 MED OTHER MYELOPROLIF DIS OR 1.3894 6.1 7.8
POORLY DIFF NEOPL DIAG W
CC.
414............. 17 MED OTHER MYELOPROLIF DIS OR .7418 3.5 4.6
POORLY DIFF NEOPL DIAG W/O
CC.
415............. 18 SURG O.R. PROCEDURE FOR 3.9067 12.6 16.3
INFECTIOUS & PARASITIC
DISEASES.
416............. 18 MED SEPTICEMIA AGE >17......... 1.6226 6.4 8.1
417............. 18 MED SEPTICEMIA AGE 0-17........ .8915 4.4 5.4
418............. 18 MED POSTOPERATIVE & POST- 1.0493 5.3 6.6
TRAUMATIC INFECTIONS.
419............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .8618 4.0 5.0
>17 W CC.
420............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .6112 3.0 3.6
>17 W/O CC.
421............. 18 MED VIRAL ILLNESS AGE >17...... .6640 3.2 3.9
422............. 18 MED VIRAL ILLNESS & FEVER OF .4757 2.6 3.1
UNKNOWN ORIGIN AGE 0-17.
423............. 18 MED OTHER INFECTIOUS & 1.8365 6.7 9.0
PARASITIC DISEASES
DIAGNOSES.
424............. 19 SURG O.R. PROCEDURE W PRINCIPAL 2.4518 10.9 15.9
DIAGNOSES OF MENTAL
ILLNESS.
425............. 19 MED ACUTE ADJUSTMENT REACTION & .6789 3.2 4.2
PSYCHOSOCIAL DYSFUNCTION.
[[Page 40062]]
426............. 19 MED DEPRESSIVE NEUROSES........ .5261 3.5 4.7
427............. 19 MED NEUROSES EXCEPT DEPRESSIVE. .5348 3.5 5.0
428............. 19 MED DISORDERS OF PERSONALITY & .7242 5.0 7.8
IMPULSE CONTROL.
429............. 19 MED ORGANIC DISTURBANCES & .8367 5.2 6.9
MENTAL RETARDATION.
430............. 19 MED PSYCHOSES.................. .7676 6.7 8.9
431............. 19 MED CHILDHOOD MENTAL DISORDERS. .6416 5.1 7.1
432............. 19 MED OTHER MENTAL DISORDER .7100 3.4 5.1
DIAGNOSES.
433............. 20 MED ALCOHOL/DRUG ABUSE OR .2888 2.3 3.2
DEPENDENCE, LEFT AMA.
434............. 20 MED NO LONGER VALID............ .0000 .0 .0
435............. 20 MED NO LONGER VALID............ .0000 .0 .0
436............. 20 MED NO LONGER VALID............ .0000 .0 .0
437............. 20 MED NO LONGER VALID............ .0000 .0 .0
438............. 20 .................... NO LONGER VALID............ .0000 .0 .0
439............. 21 SURG SKIN GRAFTS FOR INJURIES... 1.9332 6.7 9.5
440............. 21 SURG WOUND DEBRIDEMENTS FOR 2.0806 7.2 10.3
INJURIES.
441............. 21 SURG HAND PROCEDURES FOR .9295 2.3 3.3
INJURIES.
442............. 21 SURG OTHER O.R. PROCEDURES FOR 2.5304 6.8 9.6
INJURIES W CC.
443............. 21 SURG OTHER O.R. PROCEDURES FOR .9920 2.7 3.6
INJURIES W/O CC.
444............. 21 MED TRAUMATIC INJURY AGE >17 W .7277 3.4 4.4
CC.
445............. 21 MED TRAUMATIC INJURY AGE >17 W/ .4716 2.4 3.0
O CC.
446............. 21 MED *TRAUMATIC INJURY AGE 0-17. .2959 2.4 2.4
447............. 21 MED ALLERGIC REACTIONS AGE >17. .4825 1.8 2.5
448............. 21 MED *ALLERGIC REACTIONS AGE 0- .0973 2.9 2.9
17.
449............. 21 MED POISONING & TOXIC EFFECTS .8309 2.8 4.0
OF DRUGS AGE >17 W CC.
450............. 21 MED POISONING & TOXIC EFFECTS .4139 1.6 2.0
OF DRUGS AGE >17 W/O CC.
451............. 21 MED *POISONING & TOXIC EFFECTS .2627 2.1 2.1
OF DRUGS AGE 0-17.
452............. 21 MED COMPLICATIONS OF TREATMENT 1.0122 3.8 5.2
W CC.
453............. 21 MED COMPLICATIONS OF TREATMENT .4980 2.2 2.8
W/O CC.
454............. 21 MED OTHER INJURY, POISONING & .8692 3.4 4.9
TOXIC EFFECT DIAG W CC.
455............. 21 MED OTHER INJURY, POISONING & .4630 1.9 2.6
TOXIC EFFECT DIAG W/O CC.
456............. 22 .................... NO LONGER VALID............ .0000 .0 .0
457............. 22 MED NO LONGER VALID............ .0000 .0 .0
458............. 22 SURG NO LONGER VALID............ .0000 .0 .0
459............. 22 SURG NO LONGER VALID............ .0000 .0 .0
460............. 22 MED NO LONGER VALID............ .0000 .0 .0
461............. 23 SURG O.R. PROC W DIAGNOSES OF 1.1963 2.5 4.6
OTHER CONTACT W HEALTH
SERVICES.
462............. 23 MED REHABILITATION............. 1.2125 10.4 12.3
463............. 23 MED SIGNS & SYMPTOMS W CC...... .6800 3.4 4.3
464............. 23 MED SIGNS & SYMPTOMS W/O CC.... .4628 2.5 3.1
465............. 23 MED AFTERCARE W HISTORY OF .5445 2.1 3.1
MALIGNANCY AS SECONDARY
DIAGNOSIS.
466............. 23 MED AFTERCARE W/O HISTORY OF .6416 2.3 3.8
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467............. 23 MED OTHER FACTORS INFLUENCING .4585 2.1 3.1
HEALTH STATUS.
468............. .................... EXTENSIVE O.R. PROCEDURE 3.8756 11.4 14.7
UNRELATED TO PRINCIPAL
DIAGNOSIS.
469............. .................... **PRINCIPAL DIAGNOSIS .0000 .0 .0
INVALID AS DISCHARGE
DIAGNOSIS.
470............. .................... **UNGROUPABLE.............. .0000 .0 .0
471............. 08 SURG BILATERAL OR MULTIPLE MAJOR 3.0067 5.0 5.7
JOINT PROCS OF LOWER
EXTREMITY.
472............. 22 SURG NO LONGER VALID............ .0000 .0 .0
473............. 17 SURG ACUTE LEUKEMIA W/O MAJOR 3.9324 9.8 15.1
O.R. PROCEDURE AGE >17.
474............. 04 SURG NO LONGER VALID............ .0000 .0 .0
475............. 04 MED RESPIRATORY SYSTEM 3.9253 10.0 12.7
DIAGNOSIS WITH VENTILATOR
SUPPORT.
476............. SURG PROSTATIC O.R. PROCEDURE 2.2915 10.0 12.3
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477............. SURG NON-EXTENSIVE O.R. 1.9568 6.7 9.3
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478............. 05 SURG OTHER VASCULAR PROCEDURES W 2.4161 5.9 8.2
CC.
479............. 05 SURG OTHER VASCULAR PROCEDURES W/ 1.3900 2.8 3.6
O CC.
480............. PRE SURG LIVER TRANSPLANT........... 10.9812 18.1 23.9
481............. PRE SURG BONE MARROW TRANSPLANT..... 8.0438 23.6 25.8
482............. PRE SURG TRACHEOSTOMY FOR FACE,MOUTH 3.8583 11.4 14.3
& NECK DIAGNOSES.
483............. PRE SURG TRACHEOSTOMY EXCEPT FOR 15.4629 34.2 41.5
FACE,MOUTH & NECK
DIAGNOSES.
484............. 24 SURG CRANIOTOMY FOR MULTIPLE 5.2963 11.7 14.9
SIGNIFICANT TRAUMA.
[[Page 40063]]
485............. 24 SURG LIMB REATTACHMENT, HIP AND 3.1724 8.5 10.5
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TRA.
486............. 24 SURG OTHER O.R. PROCEDURES FOR 5.2888 11.0 14.3
MULTIPLE SIGNIFICANT
TRAUMA.
487............. 24 MED OTHER MULTIPLE SIGNIFICANT 1.9585 6.3 8.2
TRAUMA.
488............. 25 SURG HIV W EXTENSIVE O.R. 5.1965 14.9 19.7
PROCEDURE.
489............. 25 MED HIV W MAJOR RELATED 1.8948 7.0 9.4
CONDITION.
490............. 25 MED HIV W OR W/O OTHER RELATED 1.0584 4.3 5.8
CONDITION.
491............. 08 SURG MAJOR JOINT & LIMB 1.6353 3.0 3.5
REATTACHMENT PROCEDURES OF
UPPER EXTREMITY.
492............. 17 MED CHEMOTHERAPY W ACUTE 4.8886 13.6 19.0
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493............. 07 SURG LAPAROSCOPIC 1.8411 4.9 6.3
CHOLECYSTECTOMY W/O C.D.E.
W CC.
494............. 07 SURG LAPAROSCOPIC .9754 1.9 2.4
CHOLECYSTECTOMY W/O C.D.E.
W/O CC.
495............. PRE SURG LUNG TRANSPLANT............ 8.8252 13.8 16.2
496............. 08 SURG COMBINED ANTERIOR/POSTERIOR 5.7281 8.6 10.5
SPINAL FUSION.
497............. 08 SURG SPINAL FUSION EXCEPT 3.2324 5.8 6.9
CERVICAL W CC.
498............. 08 SURG SPINAL FUSION EXCEPT 2.3026 3.9 4.3
CERVICAL W/O CC.
499............. 08 SURG BACK & NECK PROCEDURES 1.4507 3.8 5.0
EXCEPT SPINAL FUSION W CC.
500............. 08 SURG BACK & NECK PROCEDURES .9385 2.2 2.6
EXCEPT SPINAL FUSION W/O
CC.
501............. 08 SURG KNEE PROCEDURES W PDX OF 2.7485 9.8 11.9
INFECTION W CC.
502............. 08 SURG KNEE PROCEDURES W PDX OF 1.5544 5.9 6.9
INFECTION W/O CC.
503............. 08 SURG KNEE PROCEDURES W/O PDX OF 1.2291 3.3 4.2
INFECTION.
504............. 22 SURG EXTENSIVE 3RD DEGREE BURNS 14.1729 28.8 34.7
W SKIN GRAFT.
505............. 22 MED EXTENSIVE 3RD DEGREE BURNS 1.4994 2.0 3.4
W/O SKIN GRAFT.
506............. 22 SURG FULL THICKNESS BURN W SKIN 4.9233 15.7 19.9
GRAFT OR INHAL INJ W CC OR
SIG TRAUMA.
507............. 22 SURG FULL THICKNESS BURN W SKIN 1.8583 7.3 9.3
GRFT OR INHAL INJ W/O CC
OR SIG TRAUMA.
508............. 22 MED FULL THICKNESS BURN W/O 1.2967 6.1 8.3
SKIN GRFT OR INHAL INJ W
CC OR SIG TRAUMA.
509............. 22 MED FULL THICKNESS BURN W/O .7265 3.7 4.9
SKIN GRFT OR INH INJ W/O
CC OR SIG TRAUMA.
510............. 22 MED NON-EXTENSIVE BURNS W CC OR 1.3681 5.8 8.0
SIGNIFICANT TRAUMA.
511............. 22 MED NON-EXTENSIVE BURNS W/O CC .7656 3.6 5.2
OR SIGNIFICANT TRAUMA.
512............. PRE SURG SIMULTANEOUS PANCREAS/ 5.7813 12.7 14.9
KIDNEY TRANSPLANT.
513............. PRE SURG PANCREAS TRANSPLANT........ 5.8400 9.7 11.1
514............. 05 SURG CARDIAC DEFIBRILLATOR 6.3663 6.7 8.8
IMPLANT W CARDIAC CATH.
515............. 05 SURG CARDIAC DEFIBRILLATOR 4.9905 4.2 6.7
IMPLANT W/O CARDIAC CATH.
516............. 05 SURG PERCUTANEOUS CARDIOVASC 2.7475 4.1 5.0
PROC W AMI.
517............. 05 SURG PERC CARDIO PROC W CORONARY 2.1379 1.9 2.7
ARTERY STENT W/O AMI.
518............. 05 SURG PERC CARDIO PROC W/O 1.6989 2.5 3.7
CORONARY ARTERY STENT OR
AMI.
519............. 08 SURG CERVICAL SPINAL FUSION W CC 2.3249 3.8 5.6
520............. 08 SURG CERVICAL SPINAL FUSION W/O 1.4195 1.7 2.2
CC.
521............. 20 MED ALCOHOL/DRUG ABUSE OR .7355 5.0 6.4
DEPENDENCE W CC.
522............. 20 MED ALC/DRUG ABUSE OR DEPEND W .6249 8.6 10.4
REHABILITATION THERAPY W/O
CC.
523............. 20 MED ALC/DRUG ABUSE OR DEPEND W/ .3997 3.5 4.3
O REHABILITATION THERAPY W/
O CC.
----------------------------------------------------------------------------------------------------------------
*Medicare data have been supplemented by data from 19 states for low volume DRGs.
**DRGs 469 and 470 contain cases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is presented for informational purposes only.
Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.
Federal Register / Vol. 66, No. 148 / Wednesday, August 1, 2001 /
Rules and Regulations
[[Page 40063]]
Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
Code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
256.31 Premature menopause.......... N 13 358, 359, 369
256.39 Other ovarian failure........ N 13 358, 359, 369
277.7 Dysmetabolic Syndrome X...... N 10 299
464.00 Acute laryngitis, without N 3 68, 69, 70
mention of obstruction. pre 482
464.01 Acute laryngitis, with N 3 68, 69, 70
obstruction. pre 482
[[Page 40064]]
464.50 Unspecified supraglottis, N 3 68, 69, 70
without mention of pre 482
obstruction.
464.51 Unspecified supraglottis, N 3 68, 69, 70
with obstruction. pre 482
521.00 Unspecified dental caries.... N 3 185, 186, 187
pre 482
521.01 Dental caries limited to N 3 185, 186, 187
enamel. pre 482
521.02 Dental caries extending into N 3 185, 186, 187
dentine. pre 482
521.03 Dental caries extending into N 3 185, 186, 187
pulp. pre 482
521.04 Arrested dental caries....... N 3 185, 186, 187
pre 482
521.05 Odontoclasia................. N 3 185, 186, 187
pre 482
521.09 Other dental caries.......... N 3 185, 186, 187
pre 482
525.10 Unspecified acquired absence N 3 185, 186, 187
of teeth. pre 482
525.11 Loss of teeth due to trauma.. N 3 185, 186, 187
pre 482
525.12 Loss of teeth due to N 3 185, 186, 187
periodontal disease. pre 482
525.13 Loss of teeth due to caries.. N 3 185, 186, 187
pre 482
525.19 Other loss of teeth.......... N 3 185, 186, 187
pre 482
530.12 Acute esophagitis............ N 6 182, 183, 184
564.00 Unspecified constipation..... N 6 182, 183, 184
564.01 Slow transit constipation.... N 6 182, 183, 184
564.02 Outlet dysfunction N 6 182, 183, 184
constipation.
564.09 Other constipation........... N 6 182, 183, 184
602.3 Dysplasia of prostate........ N 12 352
608.82 Hematospermia................ N 12 352
608.87 Retrograde ejaculation....... N 12 352
692.76 Sunburn of second degree..... N 9 283, 284
692.77 Sunburn of third degree...... N 9 283, 284
718.70 Developmental dislocation of N 8 256
joint, site unspecified.
718.71 Developmental dislocation of N 8 256
joint, shoulder region.
718.72 Developmental dislocation of N 8 256
joint, upper arm.
718.73 Developmental dislocation of N 8 256
joint, forearm.
718.74 Developmental dislocation of N 8 256
joint, hand.
718.75 Developmental dislocation of N 8 256
joint, pelvic region and
thigh.
718.76 Developmental dislocation of N 8 256
joint, lower leg.
718.77 Developmental dislocation of N 8 256
joint, ankle and foot.
718.78 Developmental dislocation of N 8 256
joint, other specified sites.
718.79 Developmental dislocation of N 8 256
joint, multiple sites.
733.93 Stress fracture of tibia or Y 8 239
fibula.
733.94 Stress fracture of the Y 8 239
metatarsals.
733.95 Stress fracture of other bone Y 8 239
772.10 Intraventricular hemorrhage, Y 15 387, 389
unspecified grade.
772.11 Intraventricular hemorrhage, Y 15 387, 389
Grade I.
772.12 Intraventricular hemorrhage, Y 15 387, 389
Grade II.
772.13 Intraventricular hemorrhage, Y 15 387, 389
Grade III.
772.14 Intraventricular hemorrhage, Y 15 387, 389
Grade IV.
779.7 Perventricular leukomalacia.. Y 15 387, 389
793.80 Unspecified abnormal N 9 276
mammogram.
793.81 Mammographic N 9 276
microcalcification.
793.89 Other abnormal findings on N 9 276
radiological examination
breast.
840.7 Superior glenoid labrum N 8 253, 254, 255
lesions (SLAP). 24 487
997.71 Vascular complications of Y 6 188, 189, 190
mesenteric artery. 15 387, 389
997.72 Vascular complications of Y 11 331, 332, 333
renal artery. 15 387, 389
997.79 Vascular complications of Y 5 130, 131
other vessels. 15 387, 389
V10.53 Personal history of malignant N 17 411, 412
neoplasm, renal pelvis.
V45.84 Dental restoration status.... N 23 467
V49.82 Dental sealant status........ N 23 467
[[Page 40065]]
V83.01 Asymptomatic hemophilia A N 23 467
carrier.
V83.02 Symptomatic hemophilia A N 23 467
carrier.
----------------------------------------------------------------------------------------------------------------
Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
Code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
37.28 Intracardiac echocardiography N
44.32 Percutaneous [endoscopic] Y 6 154-156
gastrojejunostomy. 7 201
10 288
17 400, 406, 407
67.51 Transabdominal cerclage of Y 13 360
cervix. 14 372, 373
21 442, 443
24 486
67.59 Other repair of internal Y 13 360
cervical os. 14 372, 373
21 442, 443
24 486
75.38 Fetal pulse oximetry......... N
81.30 Refusion of spine, not Y 1 4
otherwise specified. 8 497, 498
21 442, 443
24 486
81.31 Refusion of Atlas-axis spine. Y 1 4
8 497, 498
21 442, 443
24 486
81.32 Refusion of other cervical Y 1 4
spine, anterior technique. 8 496, 519, 520
21 442, 443
24 486
81.33 Refusion of other cervical Y 1 4
spine, posterior technique. 8 496, 519, 520
21 442, 443
24 486
81.34 Refusion of dorsal and Y 1 4
dorsolumbar spine, anterior 8 496, 497, 498
technique. 21 442, 443
24 486
81.35 Refusion of dorsal and Y 1 4
dorsolumbar spine, posterior 8 496, 497, 498
technique. 21 442, 443
24 486
81.36 Refusion of lumbar and Y 1 4
lumbosacral spine, anterior 8 496, 497, 498
technique. 21 442, 443
24 486
81.37 Refusion of lumbar and Y 1 4
lumbosacral spine, lateral 8 496, 497, 498
transverse process technique. 21 442, 443
24 486
81.38 Refusion of lumbar and Y 1 4
lumbosacral spine, posterior 8 496, 497, 498
technique. 21 442, 443
24 486
81.39 Refusion of spine, not Y 1 4
elsewhere classified. 8 497, 498
21 442, 443
24 486
97.44 Nonoperative removal of heart N
assist system.
----------------------------------------------------------------------------------------------------------------
[[Page 40066]]
Table 6C.--Invalid Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
Code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
256.3 Other ovarian failure........ N 13 358, 359, 369
464.0 Acute laryngitis............. N 3 68, 69, 70
pre 482
521.0 Dental caries................ N 3 185, 186, 187
pre 482
525.1 Loss of teeth due to N 3 185, 186, 187
accident, extraction, or pre 482
local periodontal disease.
564.0 Constipation................. N 6 182, 183, 184
772.1 Intraventricular hemorrhage.. Y 15 387, 389
793.8 Nonspecific abnormal findings N 9 276
on radiological and other
examinations of body
structure, breast.
----------------------------------------------------------------------------------------------------------------
Table 6D.--Invalid Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
Code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
67.5 Repair of internal cervical Y 13 360
os. 14 372, 373
21 442, 443
24 486
81.09 Refusion of spine, any level Y 1 4
or technique. 8 497, 498
21 442, 443
24 486
----------------------------------------------------------------------------------------------------------------
Table 6E.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
Diagnosis
Code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
411.81 Acute coronary occlusion Y 5 124, 140
without myocardial
infarction.
493.00 Extrinsic asthma without N 4 96, 97, 98
mention of status
asthmaticus or acute
exacerbation or unspecified.
493.10 Intrinsic asthma without N 4 96, 97, 98
mention of status
asthmaticus or acute
exacerbation or unspecified.
493.20 Chronic obstructive asthma Y 4 88
without mention of status
asthmaticus or acute
exacerbation or unspecified.
493.90 Asthma, unspecified without N 4 96, 97, 98
mention of status
asthmaticus or acute
exacerbation or unspecified.
V70.7 Examination of participant in N 23 467
clinical trial.
----------------------------------------------------------------------------------------------------------------
Table 6F.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
Procedure
Code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
75.34 Other fetal monitoring....... N
----------------------------------------------------------------------------------------------------------------
[[Page 40067]]
Table 6G.--Additions to the CC Exclusions List
CCs that are added to the list are in Table 6F-Additions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
------------------------------------------------------------------------
*25631 80600 82010 80637 80606 82021 77212 77210
2580 80601 82011 80638 80607 82022 77213 77211
2581 80602 82012 80639 80608 82030 77214 77212
2588 80603 82013 8064 80609 82031 7797 77213
2589 80604 82019 8065 80610 82032 *7729 77214
*25639 80605 82020 80660 80611 8208 77210 7797
2580 80606 82021 80661 80612 8209 77211 *7769
2581 80607 82022 80662 80613 82100 77212 77210
2588 80608 82030 80669 80614 82101 77213 77211
2589 80609 82031 80670 80615 82110 77214 77212
*6023 80610 82032 80671 80616 82111 7797 77213
5960 80611 8208 80672 80617 *7720 *7760 77214
5996 80612 8209 80679 80618 77210 77210 7797
6010 80613 82100 8068 80619 77211 77211 *7797
6012 80614 82101 8069 80620 77212 77212 7722
6013 80615 82110 8080 80621 77213 77213 7797
6021 80616 82111 8082 80622 77214 77214 *7798
78820 80617 *73394 8083 80623 7797 7797 77210
78829 80618 73310 80843 80624 *77210 *7761 77211
*60887 80619 73311 80849 80625 77210 77210 77212
5970 80620 73312 80851 80626 77211 77211 77213
5994 80621 73313 80852 80627 77212 77212 77214
*73310 80622 73314 80853 80628 77213 77213 7797
73393 80623 73315 80859 80629 77214 77214 *9972
73394 80624 73316 8088 80630 7722 7797 99771
73395 80625 73319 8089 80631 7797 *7762 99772
*73311 80626 73393 82000 80632 *77211 77210 99779
73393 80627 73394 82001 80633 77210 77211 *99771
73394 80628 73395 82002 80634 77211 77212 53640
73395 80629 8058 82003 80635 77212 77213 53641
*73312 80630 8059 82009 80636 77213 77214 53642
73393 80631 80600 82010 80637 77214 7797 53649
73394 80632 80601 82011 80638 7722 *7763 56962
73395 80633 80602 82012 80639 7797 77210 9974
*73313 80634 80603 82013 8064 *77212 77211 99771
73393 80635 80604 82019 8065 77210 77212 99772
73394 80636 80605 82020 80660 77211 77213 99779
73395 80637 80606 82021 80661 77212 77214 *99772
*73314 80638 80607 82022 80662 77213 7797 9975
73393 80639 80608 82030 80669 77214 *7764 99771
73394 8064 80609 82031 80670 7722 77210 99772
73395 8065 80610 82032 80671 7797 77211 99779
*73315 80660 80611 8208 80672 *77213 77212 *99779
73393 80661 80612 8209 80679 77210 77213 9972
73394 80662 80613 82100 8068 77211 77214 99771
73395 80669 80614 82101 8069 77212 7797 99772
*73316 80670 80615 82110 8080 77213 *7765 99779
73393 80671 80616 82111 8082 77214 77210 *99791
73394 80672 80617 *73395 8083 7722 77211 99771
73395 80679 80618 73310 80843 7797 77212 99772
*73319 8068 80619 73311 80849 *77214 77213 99779
73393 8069 80620 73312 80851 77210 77214 *99799
73394 8080 80621 73313 80852 77211 7797 99771
73395 8082 80622 73314 80853 77212 *7766 99772
*73393 8083 80623 73315 80859 77213 77210 99779
73310 80843 80624 73316 8088 77214 77211 *99881
73311 80849 80625 73319 8089 7722 77212 99771
73312 80851 80626 73393 82000 7797 77213 99772
73313 80852 80627 73394 82001 *7722 77214 99779
73314 80853 80628 73395 82002 77210 7797 *99883
73315 80859 80629 8058 82003 77211 *7767 99771
73316 8088 80630 8059 82009 77212 77210 99772
73319 8089 80631 80600 82010 77213 77211 99779
73393 82000 80632 80601 82011 77214 77212 *99889
73394 82001 80633 80602 82012 7797 77213 99771
73395 82002 80634 80603 82013 *7728 77214 99772
8058 82003 80635 80604 82019 77210 7797 99779
8059 82009 80636 80605 82020 77211 *7768 *9989
99771
99772
99779
------------------------------------------------------------------------
[[Page 40068]]
Table 6H.--Deletions to the CC Exclusions List
CCs that are deleted from the list are in Table 6G-Deletions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
------------------------------------------------------------------------
*2563
2580
2581
2588
2589
*7720
7721
*7721
7721
7722
*7722
7721
*7728
7721
*7729
7721
*7760
7721
*7761
7721
*7762
7721
*7763
7721
*7764
7721
*7765
7721
*7766
7721
*7767
7721
*7768
7721
*7769
7721
*7798
7721
------------------------------------------------------------------------
[[Page 40069]]
Table 7A.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
[FY2000 MEDPAR update 03/01 Grouper V18.0 ]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 34040 9.0038 2 3 6 12 19
2....................................... 6862 9.9787 3 5 8 12 20
3....................................... 2 43.5000 35 35 52 52 52
4....................................... 6110 7.1570 1 2 5 9 15
5....................................... 93853 3.1665 1 1 2 3 7
6....................................... 365 2.9671 1 1 2 4 6
7....................................... 13063 9.8610 2 4 7 12 20
8....................................... 3725 2.8969 1 1 2 4 7
9....................................... 1632 6.3192 1 3 5 8 13
10...................................... 17754 6.5545 2 3 5 8 13
11...................................... 3157 4.0744 1 2 3 5 8
12...................................... 47063 5.9088 2 3 4 7 11
13...................................... 6504 5.1948 2 3 4 6 9
14...................................... 321622 5.8761 2 3 5 7 11
15...................................... 146291 3.5528 1 2 3 4 7
16...................................... 11235 6.0446 2 3 5 7 12
17...................................... 3532 3.3061 1 2 3 4 6
18...................................... 26608 5.4190 2 3 4 7 10
19...................................... 8346 3.6416 1 2 3 5 7
20...................................... 5680 10.1768 3 5 8 13 20
21...................................... 1324 6.5249 2 3 5 8 13
22...................................... 2560 4.8176 1 2 4 6 9
23...................................... 9553 4.1807 1 2 3 5 8
24...................................... 53313 4.9825 1 2 4 6 10
25...................................... 25528 3.2186 1 2 3 4 6
26...................................... 33 2.9091 1 1 2 4 6
27...................................... 3519 5.0673 1 1 3 6 11
28...................................... 11477 6.2222 1 3 5 8 13
29...................................... 4545 3.5982 1 2 3 5 7
30...................................... 1 1.0000 1 1 1 1 1
31...................................... 3576 4.4855 1 2 3 5 8
32...................................... 1770 2.5644 1 1 2 3 5
33...................................... 1 1.0000 1 1 1 1 1
34...................................... 20753 5.0757 1 2 4 6 10
35...................................... 5893 3.3743 1 2 3 4 6
36...................................... 3217 1.4719 1 1 1 1 2
37...................................... 1465 4.0348 1 1 2 5 9
38...................................... 102 2.6569 1 1 2 3 5
39...................................... 918 1.9379 1 1 1 2 4
40...................................... 1561 3.4209 1 1 2 4 7
42...................................... 2235 2.2859 1 1 1 3 5
43...................................... 85 3.1882 1 2 3 4 6
44...................................... 1244 4.9518 2 3 4 6 9
45...................................... 2464 3.1717 1 2 3 4 6
46...................................... 3102 4.6518 1 2 4 6 9
47...................................... 1284 3.2749 1 1 3 4 6
49...................................... 2266 4.8010 1 2 3 6 9
50...................................... 2507 1.9418 1 1 1 2 3
51...................................... 205 2.6927 1 1 1 2 6
52...................................... 224 1.9196 1 1 1 2 3
53...................................... 2509 3.5787 1 1 2 4 8
54...................................... 2 1.5000 1 1 2 2 2
55...................................... 1519 2.7340 1 1 1 3 6
56...................................... 517 2.7389 1 1 2 3 5
57...................................... 712 4.0478 1 1 2 5 9
59...................................... 107 2.7850 1 1 2 3 5
60...................................... 2 3.5000 2 2 5 5 5
61...................................... 234 5.1624 1 1 2 6 13
62...................................... 3 1.3333 1 1 1 2 2
63...................................... 2955 4.3993 1 2 3 5 9
64...................................... 3070 6.1642 1 2 4 8 13
65...................................... 34702 2.8444 1 1 2 4 5
66...................................... 7035 3.1599 1 1 2 4 6
67...................................... 501 3.5768 1 2 3 4 7
68...................................... 16708 4.1241 1 2 3 5 7
69...................................... 5417 3.2845 1 2 3 4 6
70...................................... 24 2.9167 1 2 2 4 5
71...................................... 82 3.8049 1 2 3 4 7
72...................................... 893 3.5566 1 2 3 4 6
73...................................... 6690 4.3988 1 2 3 6 9
[[Page 40070]]
75...................................... 39476 9.9112 3 5 7 12 19
76...................................... 39399 11.3188 3 5 9 14 21
77...................................... 2358 4.9165 1 2 4 7 10
78...................................... 32319 6.7837 3 4 6 8 11
79...................................... 170615 8.4963 3 4 7 11 16
80...................................... 8981 5.6562 2 3 5 7 10
81...................................... 4 18.2500 3 3 4 8 58
82...................................... 62447 6.9403 2 3 5 9 14
83...................................... 6598 5.5518 2 3 4 7 10
84...................................... 1539 3.3197 1 2 3 4 6
85...................................... 20738 6.3135 2 3 5 8 12
86...................................... 2115 3.6648 1 2 3 5 7
87...................................... 60486 6.2986 1 3 5 8 12
88...................................... 395676 5.1294 2 3 4 6 9
89...................................... 529122 5.9478 2 3 5 7 11
90...................................... 53985 4.1475 2 3 4 5 7
91...................................... 57 4.4561 2 2 3 5 9
92...................................... 13873 6.3521 2 3 5 8 12
93...................................... 1692 4.0969 1 2 3 5 7
94...................................... 12158 6.3088 2 3 5 8 12
95...................................... 1621 3.7224 1 2 3 5 7
96...................................... 62414 4.6281 2 3 4 6 8
97...................................... 31618 3.6509 1 2 3 5 7
98...................................... 17 4.3529 1 2 3 4 6
99...................................... 19205 3.2061 1 1 2 4 6
100..................................... 7656 2.1813 1 1 2 3 4
101..................................... 20236 4.3987 1 2 3 5 9
102..................................... 5196 2.6522 1 1 2 3 5
103..................................... 494 47.2510 9 13 25 61 102
104..................................... 37017 11.3083 3 6 9 14 22
105..................................... 29991 9.2831 4 5 7 11 17
106..................................... 3425 11.4923 5 7 10 14 20
107..................................... 88610 10.3724 5 7 9 12 17
108..................................... 6099 10.2140 3 5 8 13 19
109..................................... 60766 7.6912 4 5 6 9 12
110..................................... 53054 9.2130 2 5 7 11 18
111..................................... 8563 4.7507 1 2 5 6 8
112..................................... 56110 3.6750 1 1 2 5 8
113..................................... 42570 12.2362 3 6 9 15 24
114..................................... 8788 8.4208 2 4 7 11 16
115..................................... 14447 8.1481 1 4 7 11 16
116..................................... 333539 3.6045 1 1 2 5 8
117..................................... 3750 4.1997 1 1 2 5 9
118..................................... 7731 2.6831 1 1 1 3 6
119..................................... 1315 4.8783 1 1 3 6 12
120..................................... 36315 8.1402 1 2 5 11 18
121..................................... 163108 6.3828 2 3 5 8 12
122..................................... 79700 3.6981 1 2 3 5 7
123..................................... 40952 4.5870 1 1 3 6 11
124..................................... 133892 4.3434 1 2 3 5 8
125..................................... 80872 2.7656 1 1 2 4 5
126..................................... 5210 11.7196 3 6 9 15 22
127..................................... 683001 5.2764 2 3 4 7 10
128..................................... 9485 5.6128 2 4 5 7 9
129..................................... 4174 2.7513 1 1 1 3 6
130..................................... 87705 5.6725 2 3 5 7 10
131..................................... 27378 4.2134 1 2 4 6 7
132..................................... 148681 3.0010 1 1 2 4 6
133..................................... 8355 2.3246 1 1 2 3 4
134..................................... 36411 3.2406 1 2 3 4 6
135..................................... 7338 4.5492 1 2 3 6 9
136..................................... 1233 2.7178 1 1 2 3 5
138..................................... 195523 3.9935 1 2 3 5 8
139..................................... 82943 2.5030 1 1 2 3 5
140..................................... 70338 2.6538 1 1 2 3 5
141..................................... 91110 3.6692 1 2 3 5 7
142..................................... 45981 2.6476 1 1 2 3 5
143..................................... 205686 2.1259 1 1 2 3 4
144..................................... 82529 5.3248 1 2 4 7 11
145..................................... 7242 2.7331 1 1 2 3 5
[[Page 40071]]
146..................................... 10755 10.3134 5 7 9 12 17
147..................................... 2637 6.4137 3 5 6 8 9
148..................................... 129971 12.2043 5 7 10 15 22
149..................................... 18528 6.5116 4 5 6 8 9
150..................................... 19921 11.2798 4 7 10 14 20
151..................................... 4858 5.8121 2 3 5 8 10
152..................................... 4399 8.1444 3 5 7 9 14
153..................................... 2100 5.3838 3 4 5 7 8
154..................................... 28871 13.1708 4 7 10 16 25
155..................................... 6655 4.2026 1 2 3 6 8
156..................................... 4 7.5000 1 1 5 6 18
157..................................... 7956 5.3910 1 2 4 7 11
158..................................... 4670 2.5362 1 1 2 3 5
159..................................... 16448 4.9962 1 2 4 6 10
160..................................... 11726 2.6594 1 1 2 3 5
161..................................... 11205 4.2062 1 1 3 5 9
162..................................... 7214 1.9211 1 1 1 2 4
163..................................... 7 3.5714 1 1 2 3 4
164..................................... 4857 8.4293 4 5 7 10 15
165..................................... 2086 4.7895 2 3 5 6 8
166..................................... 3559 5.0441 2 2 4 6 10
167..................................... 3316 2.6001 1 2 2 3 5
168..................................... 1235 4.9247 1 2 3 6 10
169..................................... 813 2.3395 1 1 2 3 5
170..................................... 11057 11.1942 2 5 8 14 22
171..................................... 1274 4.6201 1 2 4 6 9
172..................................... 30682 6.9445 2 3 5 9 14
173..................................... 2707 3.6679 1 1 3 5 7
174..................................... 242054 4.7970 2 3 4 6 9
175..................................... 32431 2.9309 1 2 3 4 5
176..................................... 15194 5.2285 2 3 4 6 10
177..................................... 9272 4.5310 2 2 4 6 8
178..................................... 3619 3.0683 1 2 3 4 6
179..................................... 12384 5.9738 2 3 5 7 11
180..................................... 86181 5.3581 2 3 4 7 10
181..................................... 26423 3.4153 1 2 3 4 6
182..................................... 234742 4.3758 1 2 3 5 8
183..................................... 81065 2.9320 1 1 2 4 5
184..................................... 78 2.9487 1 2 2 4 6
185..................................... 4769 4.5280 1 2 3 6 9
186..................................... 3 9.3333 1 1 9 18 18
187..................................... 443 4.0045 1 2 3 5 8
188..................................... 76140 5.5645 1 2 4 7 11
189..................................... 12060 3.1404 1 1 2 4 6
190..................................... 51 6.9608 2 3 4 5 8
191..................................... 8964 13.8146 4 6 10 17 27
192..................................... 1122 6.5294 2 4 6 8 11
193..................................... 5303 12.5218 5 7 10 16 22
194..................................... 721 6.7906 2 4 6 8 12
195..................................... 4350 10.1616 4 6 9 12 17
196..................................... 1166 5.7196 2 4 5 7 10
197..................................... 18895 8.9383 3 5 7 11 16
198..................................... 5786 4.5380 2 3 4 6 8
199..................................... 1725 9.6614 2 4 7 13 21
200..................................... 1081 10.3478 1 3 7 13 23
201..................................... 1413 13.7594 3 6 11 17 27
202..................................... 26168 6.4060 2 3 5 8 13
203..................................... 29251 6.6384 2 3 5 9 13
204..................................... 57757 5.7995 2 3 4 7 11
205..................................... 23128 6.1790 2 3 5 8 12
206..................................... 1970 3.8959 1 2 3 5 7
207..................................... 31072 5.0836 1 2 4 6 10
208..................................... 10149 2.8924 1 1 2 4 6
209..................................... 345519 5.0794 3 3 4 6 8
210..................................... 121933 6.8207 3 4 6 8 11
211..................................... 31780 4.9358 3 4 4 6 7
212..................................... 8 10.5000 1 1 4 9 29
213..................................... 9241 9.0019 2 4 7 11 18
216..................................... 6008 9.6949 2 4 8 12 20
217..................................... 16558 13.2636 3 5 9 16 28
[[Page 40072]]
218..................................... 21625 5.4332 2 3 4 7 10
219..................................... 19714 3.2188 1 2 3 4 6
220..................................... 6 4.0000 1 1 3 7 7
223..................................... 13397 2.8551 1 1 2 3 6
224..................................... 11274 1.9346 1 1 2 2 3
225..................................... 5805 4.8558 1 2 3 6 11
226..................................... 5235 6.5958 1 2 4 8 14
227..................................... 4703 2.7053 1 1 2 3 5
228..................................... 2373 3.7981 1 1 2 5 8
229..................................... 1119 2.4781 1 1 2 3 5
230..................................... 2401 5.2603 1 2 3 6 11
231..................................... 12308 4.9551 1 2 3 6 10
232..................................... 811 2.8792 1 1 1 3 7
233..................................... 5175 7.5314 2 3 6 10 15
234..................................... 3204 3.4263 1 1 3 4 7
235..................................... 5095 5.1460 1 2 4 6 9
236..................................... 38644 4.8192 1 3 4 6 9
237..................................... 1698 3.4953 1 2 3 4 6
238..................................... 8028 8.5896 3 4 6 10 16
239..................................... 49412 6.2190 2 3 5 8 12
240..................................... 11462 6.6902 2 3 5 8 13
241..................................... 3138 3.8368 1 2 3 5 7
242..................................... 2455 6.6550 2 3 5 8 13
243..................................... 88444 4.6699 1 2 4 6 9
244..................................... 12282 4.8026 1 2 4 6 9
245..................................... 5158 3.4420 1 2 3 4 6
246..................................... 1402 3.8759 1 2 3 5 7
247..................................... 16979 3.4022 1 1 3 4 7
248..................................... 10612 4.8149 1 2 4 6 9
249..................................... 11655 3.6913 1 1 2 4 8
250..................................... 3495 4.1021 1 2 3 5 7
251..................................... 2432 2.8647 1 1 2 4 5
253..................................... 19997 4.7768 1 3 4 6 9
254..................................... 10514 3.1844 1 2 3 4 6
255..................................... 1 3.0000 3 3 3 3 3
256..................................... 6110 5.0566 1 2 4 6 10
257..................................... 16468 2.7380 1 1 2 3 5
258..................................... 16096 1.9335 1 1 2 2 3
259..................................... 3805 2.6915 1 1 1 2 6
260..................................... 4920 1.4191 1 1 1 2 2
261..................................... 1871 2.2720 1 1 1 3 5
262..................................... 615 4.0065 1 1 3 5 8
263..................................... 23616 11.6630 3 5 8 14 23
264..................................... 4081 7.0034 2 3 5 8 14
265..................................... 3785 6.7974 1 2 4 8 14
266..................................... 2669 3.2345 1 1 2 4 7
267..................................... 233 4.2060 1 1 3 6 9
268..................................... 910 3.5824 1 1 2 4 7
269..................................... 8868 8.2049 2 3 6 10 17
270..................................... 2661 3.4540 1 1 2 4 7
271..................................... 20588 7.1370 2 4 6 9 13
272..................................... 5506 6.1593 2 3 5 8 12
273..................................... 1290 4.0233 1 2 3 5 8
274..................................... 2357 6.5965 1 3 5 8 13
275..................................... 249 4.3373 1 1 3 5 9
276..................................... 1183 4.7101 1 2 4 6 8
277..................................... 88891 5.7267 2 3 5 7 10
278..................................... 30673 4.3084 2 3 4 5 8
279..................................... 3 2.3333 1 1 2 4 4
280..................................... 15826 4.1974 1 2 3 5 8
281..................................... 7203 3.0314 1 1 3 4 6
282..................................... 3 1.6667 1 1 2 2 2
283..................................... 5701 4.5869 1 2 4 6 9
284..................................... 1863 3.0934 1 1 2 4 6
285..................................... 6259 10.2903 3 5 8 13 20
286..................................... 2081 6.4248 2 3 5 7 13
287..................................... 5745 10.5220 3 5 7 12 21
288..................................... 2705 5.7360 2 3 4 6 9
289..................................... 4801 3.0165 1 1 2 3 7
290..................................... 8818 2.3115 1 1 2 2 4
[[Page 40073]]
291..................................... 66 1.8333 1 1 1 2 3
292..................................... 5044 10.2399 2 4 8 13 20
293..................................... 385 5.3714 1 2 4 7 11
294..................................... 88615 4.6095 1 2 4 6 9
295..................................... 3318 3.7372 1 2 3 5 7
296..................................... 240055 5.1602 2 2 4 6 10
297..................................... 44040 3.4064 1 2 3 4 6
298..................................... 95 2.9158 1 1 2 4 5
299..................................... 1192 5.3079 1 2 4 7 11
300..................................... 16118 6.1471 2 3 5 8 12
301..................................... 3221 3.6107 1 2 3 4 7
302..................................... 8256 9.0922 4 5 7 10 16
303..................................... 19568 8.4192 4 5 7 10 15
304..................................... 11902 8.7432 2 4 6 11 18
305..................................... 3011 3.6430 1 2 3 5 7
306..................................... 7368 5.6221 1 2 3 8 13
307..................................... 2096 2.2457 1 1 2 3 4
308..................................... 7520 6.2090 1 2 4 8 14
309..................................... 4120 2.2998 1 1 2 3 4
310..................................... 24033 4.4040 1 1 3 6 10
311..................................... 8027 1.8343 1 1 1 2 3
312..................................... 1499 4.4957 1 1 3 6 10
313..................................... 594 2.3300 1 1 1 3 5
314..................................... 1 3.0000 3 3 3 3 3
315..................................... 30085 6.9945 1 1 4 9 16
316..................................... 105482 6.6227 2 3 5 8 13
317..................................... 1536 2.8561 1 1 2 3 6
318..................................... 5627 6.0105 1 3 5 8 12
319..................................... 428 2.7477 1 1 2 3 6
320..................................... 188146 5.3180 2 3 4 6 10
321..................................... 30418 3.7849 1 2 3 5 7
322..................................... 61 4.1475 2 2 3 5 8
323..................................... 17410 3.2221 1 1 2 4 7
324..................................... 7562 1.8803 1 1 1 2 3
325..................................... 8239 3.8229 1 2 3 5 7
326..................................... 2705 2.6699 1 1 2 3 5
327..................................... 11 3.0909 1 1 3 4 5
328..................................... 668 3.6722 1 1 3 5 8
329..................................... 76 2.0000 1 1 1 2 4
331..................................... 46575 5.5475 1 3 4 7 11
332..................................... 4939 3.2909 1 1 2 4 7
333..................................... 290 4.9828 1 2 3 6 10
334..................................... 10491 4.8593 2 3 4 6 8
335..................................... 11916 3.3087 2 2 3 4 5
336..................................... 37713 3.4950 1 2 2 4 7
337..................................... 30390 2.1186 1 1 2 3 3
338..................................... 1232 5.1080 1 2 3 7 11
339..................................... 1628 4.6161 1 1 3 6 11
340..................................... 1 1.0000 1 1 1 1 1
341..................................... 3766 3.0316 1 1 2 3 6
342..................................... 675 3.2207 1 2 2 4 6
344..................................... 3519 2.3743 1 1 1 2 5
345..................................... 1280 3.7914 1 1 2 4 8
346..................................... 4489 5.9082 1 3 4 7 12
347..................................... 366 2.9372 1 1 2 4 6
348..................................... 3077 4.1677 1 2 3 5 8
349..................................... 626 2.5335 1 1 2 3 5
350..................................... 6325 4.4024 1 2 4 5 8
352..................................... 766 3.9621 1 2 3 5 8
353..................................... 2557 6.4490 2 3 5 7 12
354..................................... 7609 5.8406 3 3 4 7 11
355..................................... 5530 3.2790 2 3 3 4 5
356..................................... 25303 2.2920 1 1 2 3 4
357..................................... 5580 8.4925 3 4 7 10 16
358..................................... 20491 4.3133 2 3 3 5 7
359..................................... 30146 2.7284 2 2 3 3 4
360..................................... 16032 2.8550 1 2 2 3 5
361..................................... 386 2.9948 1 1 2 3 5
363..................................... 2875 3.4650 1 2 2 3 7
364..................................... 1667 3.8410 1 1 3 5 8
[[Page 40074]]
365..................................... 1737 7.2239 1 3 5 9 16
366..................................... 4468 6.7258 1 3 5 8 14
367..................................... 584 3.1284 1 1 2 4 6
368..................................... 3136 6.4716 2 3 5 8 12
369..................................... 3180 3.2500 1 1 2 4 7
370..................................... 1151 5.9079 3 3 4 5 10
371..................................... 1368 3.6447 2 3 3 4 5
372..................................... 964 3.2811 1 2 2 3 5
373..................................... 3920 2.2487 1 2 2 3 3
374..................................... 130 3.0846 1 2 2 3 4
375..................................... 11 2.2727 1 2 2 2 4
376..................................... 249 3.0843 1 2 2 4 6
377..................................... 51 5.0392 1 1 4 6 12
378..................................... 158 2.4177 1 1 2 3 4
379..................................... 344 3.4506 1 1 2 4 6
380..................................... 60 2.0833 1 1 1 2 5
381..................................... 154 2.5065 1 1 1 3 5
382..................................... 45 1.2889 1 1 1 1 2
383..................................... 1746 3.6174 1 1 2 4 8
384..................................... 121 2.1488 1 1 1 2 4
385..................................... 1 1.0000 1 1 1 1 1
389..................................... 16 13.5000 1 3 6 11 24
390..................................... 14 4.0000 1 2 3 6 7
391..................................... 1 4.0000 4 4 4 4 4
392..................................... 2349 9.6841 3 4 7 12 20
394..................................... 1891 7.1364 1 2 4 8 16
395..................................... 87679 4.4004 1 2 3 6 9
396..................................... 15 4.6667 1 2 4 6 7
397..................................... 17705 5.1893 1 2 4 7 10
398..................................... 17713 5.9510 2 3 5 7 11
399..................................... 1727 3.5634 1 2 3 5 7
400..................................... 6492 9.1288 1 3 6 12 20
401..................................... 5625 11.2775 2 5 9 15 23
402..................................... 1500 4.0933 1 1 3 6 9
403..................................... 32010 8.0846 2 3 6 10 17
404..................................... 4672 4.2609 1 2 3 6 9
406..................................... 2526 9.9224 3 4 7 12 21
407..................................... 722 4.4252 1 2 4 5 8
408..................................... 2193 8.0228 1 2 5 10 18
409..................................... 2831 5.9325 2 3 4 6 12
410..................................... 33654 3.9062 1 2 4 5 6
411..................................... 13 2.3077 1 1 2 2 5
412..................................... 30 2.4000 1 1 2 3 4
413..................................... 6478 7.0869 2 3 5 9 14
414..................................... 780 4.2885 1 2 3 5 9
415..................................... 39078 14.3458 4 6 11 18 28
416..................................... 184735 7.3935 2 4 6 9 14
417..................................... 18 5.0000 1 2 4 7 9
418..................................... 23028 6.1229 2 3 5 7 12
419..................................... 15460 4.7254 2 2 4 6 9
420..................................... 3116 3.4881 1 2 3 4 6
421..................................... 11535 3.7877 1 2 3 5 7
422..................................... 83 3.0482 1 2 3 4 6
423..................................... 7539 8.1108 2 3 6 10 16
424..................................... 1308 13.6338 2 5 9 16 26
425..................................... 15852 3.9953 1 2 3 5 8
426..................................... 4552 4.4512 1 2 3 5 9
427..................................... 1669 4.6207 1 2 3 6 9
428..................................... 854 6.9859 1 2 4 8 14
429..................................... 26786 6.3438 2 3 5 7 12
430..................................... 59892 8.0207 2 3 6 10 16
431..................................... 319 6.4326 1 3 5 7 12
432..................................... 475 4.7684 1 2 3 5 9
433..................................... 5522 3.0996 1 1 2 4 6
434..................................... 23062 5.0233 1 2 4 6 9
435..................................... 15012 4.1096 1 2 3 5 7
436..................................... 3158 12.8322 4 7 11 18 27
437..................................... 8588 8.6778 3 5 8 11 15
439..................................... 1356 8.3857 1 3 5 10 18
440..................................... 5191 9.0326 2 3 6 11 20
[[Page 40075]]
441..................................... 604 3.2235 1 1 2 4 7
442..................................... 15588 8.4766 1 3 6 10 18
443..................................... 3738 3.4315 1 1 3 4 7
444..................................... 5303 4.1495 1 2 3 5 8
445..................................... 2450 2.8857 1 1 2 4 5
447..................................... 5497 2.4708 1 1 2 3 5
449..................................... 28365 3.7491 1 1 3 5 8
450..................................... 6935 1.9981 1 1 1 2 4
451..................................... 3 1.3333 1 1 1 2 2
452..................................... 22930 4.8560 1 2 3 6 10
453..................................... 5095 2.7978 1 1 2 3 5
454..................................... 4001 4.5431 1 2 3 5 9
455..................................... 939 2.5751 1 1 2 3 5
461..................................... 3677 4.3723 1 1 2 5 11
462..................................... 13083 11.2728 4 6 10 14 21
463..................................... 22068 4.1282 1 2 3 5 8
464..................................... 6542 3.0011 1 1 2 4 6
465..................................... 248 3.0202 1 1 2 4 6
466..................................... 1741 3.7030 1 1 2 4 8
467..................................... 1137 3.0633 1 1 2 3 6
468..................................... 59766 12.9438 3 6 10 17 26
471..................................... 11720 5.5506 3 4 4 6 9
473..................................... 7663 12.5910 1 3 7 18 32
475..................................... 107894 11.2229 2 5 9 15 22
476..................................... 4142 10.8841 2 5 9 14 21
477..................................... 25336 8.1162 1 3 6 11 17
478..................................... 108852 7.3022 1 3 5 9 15
479..................................... 24100 3.4573 1 1 3 4 7
480..................................... 562 20.9609 7 9 14 25 44
481..................................... 383 24.1253 10 18 22 27 39
482..................................... 5733 12.9843 4 7 10 15 25
483..................................... 42784 39.4479 14 22 33 49 71
484..................................... 331 13.0091 2 6 10 17 26
485..................................... 2959 9.7080 4 5 7 11 18
486..................................... 2017 12.4408 1 5 10 16 25
487..................................... 3506 7.3945 1 3 6 10 15
488..................................... 784 16.9031 3 7 12 22 36
489..................................... 14140 8.4372 2 3 6 10 17
490..................................... 5449 5.3577 1 2 4 6 11
491..................................... 12291 3.4475 2 2 3 4 6
492..................................... 2698 15.6675 3 5 8 25 34
493..................................... 55279 5.7576 1 3 5 7 11
494..................................... 30109 2.4447 1 1 2 3 5
495..................................... 159 15.0503 7 9 12 17 26
496..................................... 1475 9.7349 4 5 7 12 19
497..................................... 22725 6.1720 2 3 5 7 12
498..................................... 21513 3.3043 1 2 3 4 6
499..................................... 31077 4.7330 1 2 3 6 9
500..................................... 44660 2.6198 1 1 2 3 5
501..................................... 2200 10.9600 4 6 8 13 21
502..................................... 585 6.5692 3 4 5 8 11
503..................................... 5631 4.0012 1 2 3 5 7
504..................................... 118 30.5169 9 15 24 41 55
505..................................... 145 3.3517 1 1 1 3 7
506..................................... 931 17.4071 4 8 14 22 36
507..................................... 293 8.3379 2 4 7 11 18
508..................................... 671 7.4918 2 3 5 9 15
509..................................... 177 4.5367 1 2 4 6 9
510..................................... 1650 7.2358 2 3 5 9 15
511..................................... 608 4.8158 1 2 3 6 11
----------------
11079177
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 40076]]
Table 7B.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
[FY2000 MEDPAR update 03/01 Grouper V19.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 34040 9.0038 2 3 6 12 19
2....................................... 6862 9.9787 3 5 8 12 20
3....................................... 2 43.5000 35 35 52 52 52
4....................................... 6120 7.1526 1 2 5 9 15
5....................................... 93853 3.1665 1 1 2 3 7
6....................................... 365 2.9671 1 1 2 4 6
7....................................... 13283 9.8362 2 4 7 12 20
8....................................... 3821 2.9089 1 1 2 4 7
9....................................... 1631 6.3194 1 3 5 8 13
10...................................... 17754 6.5545 2 3 5 8 13
11...................................... 3157 4.0744 1 2 3 5 8
12...................................... 47063 5.9088 2 3 4 7 11
13...................................... 6504 5.1948 2 3 4 6 9
14...................................... 321622 5.8761 2 3 5 7 11
15...................................... 146291 3.5528 1 2 3 4 7
16...................................... 11235 6.0446 2 3 5 7 12
17...................................... 3532 3.3061 1 2 3 4 6
18...................................... 26608 5.4190 2 3 4 7 10
19...................................... 8346 3.6416 1 2 3 5 7
20...................................... 5680 10.1768 3 5 8 13 20
21...................................... 1324 6.5249 2 3 5 8 13
22...................................... 2560 4.8176 1 2 4 6 9
23...................................... 9553 4.1807 1 2 3 5 8
24...................................... 53313 4.9825 1 2 4 6 10
25...................................... 25528 3.2186 1 2 3 4 6
26...................................... 33 2.9091 1 1 2 4 6
27...................................... 3519 5.0673 1 1 3 6 11
28...................................... 11477 6.2222 1 3 5 8 13
29...................................... 4545 3.5982 1 2 3 5 7
30...................................... 1 1.0000 1 1 1 1 1
31...................................... 3576 4.4855 1 2 3 5 8
32...................................... 1770 2.5644 1 1 2 3 5
33...................................... 1 1.0000 1 1 1 1 1
34...................................... 20751 5.0759 1 2 4 6 10
35...................................... 5893 3.3743 1 2 3 4 6
36...................................... 3217 1.4719 1 1 1 1 2
37...................................... 1465 4.0348 1 1 2 5 9
38...................................... 102 2.6569 1 1 2 3 5
39...................................... 918 1.9379 1 1 1 2 4
40...................................... 1561 3.4209 1 1 2 4 7
42...................................... 2235 2.2859 1 1 1 3 5
43...................................... 85 3.1882 1 2 3 4 6
44...................................... 1244 4.9518 2 3 4 6 9
45...................................... 2464 3.1717 1 2 3 4 6
46...................................... 3102 4.6518 1 2 4 6 9
47...................................... 1284 3.2749 1 1 3 4 6
49...................................... 2266 4.8010 1 2 3 6 9
50...................................... 2507 1.9418 1 1 1 2 3
51...................................... 205 2.6927 1 1 1 2 6
52...................................... 224 1.9196 1 1 1 2 3
53...................................... 2512 3.5760 1 1 2 4 8
54...................................... 2 1.5000 1 1 2 2 2
55...................................... 1521 2.7331 1 1 1 3 6
56...................................... 517 2.7389 1 1 2 3 5
57...................................... 712 4.0478 1 1 2 5 9
59...................................... 107 2.7850 1 1 2 3 5
60...................................... 2 3.5000 2 2 5 5 5
61...................................... 234 5.1624 1 1 2 6 13
62...................................... 3 1.3333 1 1 1 2 2
63...................................... 3039 4.4399 1 2 3 5 9
64...................................... 3070 6.1642 1 2 4 8 13
65...................................... 34702 2.8444 1 1 2 4 5
66...................................... 7035 3.1599 1 1 2 4 6
67...................................... 501 3.5768 1 2 3 4 7
68...................................... 16804 4.1202 1 2 3 5 7
69...................................... 5465 3.2767 1 2 3 4 6
70...................................... 24 2.9167 1 2 2 4 5
71...................................... 82 3.8049 1 2 3 4 7
72...................................... 893 3.5566 1 2 3 4 6
73...................................... 6690 4.3988 1 2 3 6 9
[[Page 40077]]
75...................................... 39476 9.9112 3 5 7 12 19
76...................................... 40377 11.4074 3 5 9 14 22
77...................................... 2406 5.0000 1 2 4 7 10
78...................................... 32319 6.7837 3 4 6 8 11
79...................................... 170615 8.4963 3 4 7 11 16
80...................................... 8981 5.6562 2 3 5 7 10
81...................................... 4 18.2500 3 3 4 8 58
82...................................... 62447 6.9403 2 3 5 9 14
83...................................... 6598 5.5518 2 3 4 7 10
84...................................... 1539 3.3197 1 2 3 4 6
85...................................... 20738 6.3135 2 3 5 8 12
86...................................... 2115 3.6648 1 2 3 5 7
87...................................... 60486 6.2986 1 3 5 8 12
88...................................... 395676 5.1294 2 3 4 6 9
89...................................... 529122 5.9478 2 3 5 7 11
90...................................... 53985 4.1475 2 3 4 5 7
91...................................... 57 4.4561 2 2 3 5 9
92...................................... 13873 6.3521 2 3 5 8 12
93...................................... 1692 4.0969 1 2 3 5 7
94...................................... 12158 6.3088 2 3 5 8 12
95...................................... 1621 3.7224 1 2 3 5 7
96...................................... 62414 4.6281 2 3 4 6 8
97...................................... 31618 3.6509 1 2 3 5 7
98...................................... 17 4.3529 1 2 3 4 6
99...................................... 19205 3.2061 1 1 2 4 6
100..................................... 7656 2.1813 1 1 2 3 4
101..................................... 20236 4.3987 1 2 3 5 9
102..................................... 5196 2.6522 1 1 2 3 5
103..................................... 494 47.2510 9 13 25 61 102
104..................................... 19992 14.2362 6 8 12 17 25
105..................................... 26203 9.7712 4 6 8 11 17
106..................................... 3425 11.4923 5 7 10 14 20
107..................................... 88610 10.3724 5 7 9 12 17
108..................................... 6099 10.2140 3 5 8 13 19
109..................................... 60766 7.6912 4 5 6 9 12
110..................................... 53054 9.2130 2 5 7 11 18
111..................................... 8563 4.7507 1 2 5 6 8
113..................................... 42570 12.2362 3 6 9 15 24
114..................................... 8788 8.4208 2 4 7 11 16
115..................................... 14447 8.1481 1 4 7 11 16
116..................................... 101326 4.5123 1 2 3 6 9
117..................................... 3750 4.1997 1 1 2 5 9
118..................................... 7731 2.6831 1 1 1 3 6
119..................................... 1315 4.8783 1 1 3 6 12
120..................................... 37900 8.5509 1 2 6 11 19
121..................................... 163108 6.3828 2 3 5 8 12
122..................................... 79700 3.6981 1 2 3 5 7
123..................................... 40952 4.5870 1 1 3 6 11
124..................................... 133892 4.3434 1 2 3 5 8
125..................................... 80872 2.7656 1 1 2 4 5
126..................................... 5210 11.7196 3 6 9 15 22
127..................................... 683001 5.2764 2 3 4 7 10
128..................................... 9485 5.6128 2 4 5 7 9
129..................................... 4174 2.7513 1 1 1 3 6
130..................................... 87705 5.6725 2 3 5 7 10
131..................................... 27378 4.2134 1 2 4 6 7
132..................................... 148681 3.0010 1 1 2 4 6
133..................................... 8355 2.3246 1 1 2 3 4
134..................................... 36411 3.2406 1 2 3 4 6
135..................................... 7338 4.5492 1 2 3 6 9
136..................................... 1233 2.7178 1 1 2 3 5
138..................................... 195523 3.9935 1 2 3 5 8
139..................................... 82943 2.5030 1 1 2 3 5
140..................................... 70338 2.6538 1 1 2 3 5
141..................................... 91110 3.6692 1 2 3 5 7
142..................................... 45981 2.6476 1 1 2 3 5
143..................................... 205686 2.1259 1 1 2 3 4
144..................................... 82529 5.3248 1 2 4 7 11
145..................................... 7242 2.7331 1 1 2 3 5
146..................................... 10755 10.3134 5 7 9 12 17
[[Page 40078]]
147..................................... 2637 6.4137 3 5 6 8 9
148..................................... 130066 12.2031 5 7 10 15 22
149..................................... 18560 6.5100 4 5 6 8 9
150..................................... 19923 11.2795 4 7 10 14 20
151..................................... 4860 5.8123 2 3 5 8 10
152..................................... 4399 8.1444 3 5 7 9 14
153..................................... 2100 5.3838 3 4 5 7 8
154..................................... 28872 13.1709 4 7 10 16 25
155..................................... 6655 4.2026 1 2 3 6 8
156..................................... 4 7.5000 1 1 5 6 18
157..................................... 7963 5.3929 1 2 4 7 11
158..................................... 4671 2.5359 1 1 2 3 5
159..................................... 16456 4.9981 1 2 4 6 10
160..................................... 11727 2.6592 1 1 2 3 5
161..................................... 11208 4.2057 1 1 3 5 9
162..................................... 7217 1.9216 1 1 1 2 4
163..................................... 7 3.5714 1 1 2 3 4
164..................................... 4857 8.4293 4 5 7 10 15
165..................................... 2086 4.7895 2 3 5 6 8
166..................................... 3559 5.0441 2 2 4 6 10
167..................................... 3316 2.6001 1 2 2 3 5
168..................................... 1361 4.7649 1 2 3 6 10
169..................................... 843 2.3238 1 1 2 3 5
170..................................... 12291 10.9867 2 4 8 14 22
171..................................... 1408 4.5014 1 2 4 6 9
172..................................... 30682 6.9445 2 3 5 9 14
173..................................... 2707 3.6679 1 1 3 5 7
174..................................... 242053 4.7969 2 3 4 6 9
175..................................... 32431 2.9309 1 2 3 4 5
176..................................... 15194 5.2285 2 3 4 6 10
177..................................... 9272 4.5310 2 2 4 6 8
178..................................... 3619 3.0683 1 2 3 4 6
179..................................... 12384 5.9738 2 3 5 7 11
180..................................... 86181 5.3581 2 3 4 7 10
181..................................... 26423 3.4153 1 2 3 4 6
182..................................... 245515 4.3381 1 2 3 5 8
183..................................... 84480 2.9129 1 1 2 4 5
184..................................... 80 2.9500 1 2 2 4 6
185..................................... 4826 4.5089 1 2 3 6 9
186..................................... 3 9.3333 1 1 9 18 18
187..................................... 683 3.9253 1 1 3 5 8
188..................................... 76140 5.5645 1 2 4 7 11
189..................................... 12060 3.1404 1 1 2 4 6
190..................................... 51 6.9608 2 3 4 5 8
191..................................... 8941 13.8186 4 6 10 17 27
192..................................... 1122 6.5294 2 4 6 8 11
193..................................... 5303 12.5218 5 7 10 16 22
194..................................... 721 6.7906 2 4 6 8 12
195..................................... 4350 10.1616 4 6 9 12 17
196..................................... 1166 5.7196 2 4 5 7 10
197..................................... 18895 8.9383 3 5 7 11 16
198..................................... 5786 4.5380 2 3 4 6 8
199..................................... 1725 9.6614 2 4 7 13 21
200..................................... 1081 10.3478 1 3 7 13 23
201..................................... 1431 13.7393 3 6 11 17 27
202..................................... 26168 6.4060 2 3 5 8 13
203..................................... 29251 6.6384 2 3 5 9 13
204..................................... 57757 5.7995 2 3 4 7 11
205..................................... 23128 6.1790 2 3 5 8 12
206..................................... 1970 3.8959 1 2 3 5 7
207..................................... 31072 5.0836 1 2 4 6 10
208..................................... 10149 2.8924 1 1 2 4 6
209..................................... 345519 5.0794 3 3 4 6 8
210..................................... 121933 6.8207 3 4 6 8 11
211..................................... 31780 4.9358 3 4 4 6 7
212..................................... 8 10.5000 1 1 4 9 29
213..................................... 9241 9.0019 2 4 7 11 18
216..................................... 6008 9.6949 2 4 8 12 20
217..................................... 16558 13.2636 3 5 9 16 28
218..................................... 21621 5.4328 2 3 4 7 10
[[Page 40079]]
219..................................... 19714 3.2188 1 2 3 4 6
220..................................... 6 4.0000 1 1 3 7 7
223..................................... 13397 2.8551 1 1 2 3 6
224..................................... 11274 1.9346 1 1 2 2 3
225..................................... 5805 4.8558 1 2 3 6 11
226..................................... 5230 6.5887 1 2 4 8 14
227..................................... 4702 2.7052 1 1 2 3 5
228..................................... 2373 3.7981 1 1 2 5 8
229..................................... 1118 2.4785 1 1 2 3 5
230..................................... 2395 5.2551 1 2 3 6 11
231..................................... 11467 4.9383 1 2 3 6 11
232..................................... 811 2.8792 1 1 1 3 7
233..................................... 5159 7.5251 1 3 6 10 15
234..................................... 3186 3.4203 1 1 3 4 7
235..................................... 5095 5.1460 1 2 4 6 9
236..................................... 38644 4.8192 1 3 4 6 9
237..................................... 1698 3.4953 1 2 3 4 6
238..................................... 8028 8.5896 3 4 6 10 16
239..................................... 49410 6.2190 2 3 5 8 12
240..................................... 11462 6.6902 2 3 5 8 13
241..................................... 3138 3.8368 1 2 3 5 7
242..................................... 2455 6.6550 2 3 5 8 13
243..................................... 88325 4.6695 1 2 4 6 9
244..................................... 12281 4.8027 1 2 4 6 9
245..................................... 5158 3.4420 1 2 3 4 6
246..................................... 1402 3.8759 1 2 3 5 7
247..................................... 16979 3.4022 1 1 3 4 7
248..................................... 10612 4.8149 1 2 4 6 9
249..................................... 11431 3.6726 1 1 2 4 8
250..................................... 3495 4.1021 1 2 3 5 7
251..................................... 2432 2.8647 1 1 2 4 5
253..................................... 19997 4.7768 1 3 4 6 9
254..................................... 10514 3.1844 1 2 3 4 6
255..................................... 1 3.0000 3 3 3 3 3
256..................................... 6097 5.0576 1 2 4 6 10
257..................................... 16468 2.7380 1 1 2 3 5
258..................................... 16096 1.9335 1 1 2 2 3
259..................................... 3805 2.6915 1 1 1 2 6
260..................................... 4920 1.4191 1 1 1 2 2
261..................................... 1875 2.2704 1 1 1 3 5
262..................................... 622 3.9807 1 1 3 5 8
263..................................... 23616 11.6630 3 5 8 14 23
264..................................... 4081 7.0034 2 3 5 8 14
265..................................... 3785 6.7974 1 2 4 8 14
266..................................... 2669 3.2345 1 1 2 4 7
267..................................... 233 4.2060 1 1 3 6 9
268..................................... 910 3.5824 1 1 2 4 7
269..................................... 8868 8.2049 2 3 6 10 17
270..................................... 2662 3.4530 1 1 2 4 7
271..................................... 20588 7.1370 2 4 6 9 13
272..................................... 5506 6.1593 2 3 5 8 12
273..................................... 1290 4.0233 1 2 3 5 8
274..................................... 2357 6.5965 1 3 5 8 13
275..................................... 249 4.3373 1 1 3 5 9
276..................................... 1189 4.7258 1 2 4 6 8
277..................................... 88891 5.7267 2 3 5 7 10
278..................................... 30673 4.3084 2 3 4 5 8
279..................................... 3 2.3333 1 1 2 4 4
280..................................... 15826 4.1974 1 2 3 5 8
281..................................... 7203 3.0314 1 1 3 4 6
282..................................... 3 1.6667 1 1 2 2 2
283..................................... 5701 4.5869 1 2 4 6 9
284..................................... 1863 3.0934 1 1 2 4 6
285..................................... 6259 10.2903 3 5 8 13 20
286..................................... 2081 6.4248 2 3 5 7 13
287..................................... 5745 10.5220 3 5 7 12 21
288..................................... 2705 5.7360 2 3 4 6 9
289..................................... 4801 3.0165 1 1 2 3 7
290..................................... 8818 2.3115 1 1 2 2 4
291..................................... 66 1.8333 1 1 1 2 3
[[Page 40080]]
292..................................... 4994 10.2367 2 4 8 13 20
293..................................... 385 5.3714 1 2 4 7 11
294..................................... 88615 4.6095 1 2 4 6 9
295..................................... 3318 3.7372 1 2 3 5 7
296..................................... 240050 5.1602 2 2 4 6 10
297..................................... 44040 3.4064 1 2 3 4 6
298..................................... 95 2.9158 1 1 2 4 5
299..................................... 1192 5.3079 1 2 4 7 11
300..................................... 16118 6.1471 2 3 5 8 12
301..................................... 3221 3.6107 1 2 3 4 7
302..................................... 7924 8.8892 4 5 7 10 15
303..................................... 19568 8.4192 4 5 7 10 15
304..................................... 11900 8.7432 2 4 6 11 18
305..................................... 3011 3.6430 1 2 3 5 7
306..................................... 7368 5.6221 1 2 3 8 13
307..................................... 2096 2.2457 1 1 2 3 4
308..................................... 7520 6.2090 1 2 4 8 14
309..................................... 4120 2.2998 1 1 2 3 4
310..................................... 24033 4.4040 1 1 3 6 10
311..................................... 8027 1.8343 1 1 1 2 3
312..................................... 1499 4.4957 1 1 3 6 10
313..................................... 594 2.3300 1 1 1 3 5
314..................................... 1 3.0000 3 3 3 3 3
315..................................... 30492 7.1080 1 1 4 9 16
316..................................... 105482 6.6227 2 3 5 8 13
317..................................... 1536 2.8561 1 1 2 3 6
318..................................... 5627 6.0105 1 3 5 8 12
319..................................... 428 2.7477 1 1 2 3 6
320..................................... 188146 5.3180 2 3 4 6 10
321..................................... 30418 3.7849 1 2 3 5 7
322..................................... 61 4.1475 2 2 3 5 8
323..................................... 17410 3.2221 1 1 2 4 7
324..................................... 7562 1.8803 1 1 1 2 3
325..................................... 8239 3.8229 1 2 3 5 7
326..................................... 2705 2.6699 1 1 2 3 5
327..................................... 11 3.0909 1 1 3 4 5
328..................................... 668 3.6722 1 1 3 5 8
329..................................... 76 2.0000 1 1 1 2 4
331..................................... 46575 5.5475 1 3 4 7 11
332..................................... 4939 3.2909 1 1 2 4 7
333..................................... 290 4.9828 1 2 3 6 10
334..................................... 10491 4.8593 2 3 4 6 8
335..................................... 11916 3.3087 2 2 3 4 5
336..................................... 37713 3.4950 1 2 2 4 7
337..................................... 30390 2.1186 1 1 2 3 3
338..................................... 1232 5.1080 1 2 3 7 11
339..................................... 1628 4.6161 1 1 3 6 11
340..................................... 1 1.0000 1 1 1 1 1
341..................................... 3766 3.0316 1 1 2 3 6
342..................................... 675 3.2207 1 2 2 4 6
344..................................... 3519 2.3743 1 1 1 2 5
345..................................... 1280 3.7914 1 1 2 4 8
346..................................... 4489 5.9082 1 3 4 7 12
347..................................... 366 2.9372 1 1 2 4 6
348..................................... 3077 4.1677 1 2 3 5 8
349..................................... 626 2.5335 1 1 2 3 5
350..................................... 6325 4.4024 1 2 4 5 8
352..................................... 766 3.9621 1 2 3 5 8
353..................................... 2557 6.4490 2 3 5 7 12
354..................................... 7609 5.8406 3 3 4 7 11
355..................................... 5530 3.2790 2 3 3 4 5
356..................................... 25303 2.2920 1 1 2 3 4
357..................................... 5580 8.4925 3 4 7 10 16
358..................................... 20492 4.3132 2 3 3 5 7
359..................................... 30149 2.7284 2 2 3 3 4
360..................................... 16035 2.8549 1 2 2 3 5
361..................................... 386 2.9948 1 1 2 3 5
363..................................... 2875 3.4650 1 2 2 3 7
364..................................... 1666 3.8427 1 1 3 5 8
365..................................... 1737 7.2239 1 3 5 9 16
[[Page 40081]]
366..................................... 4468 6.7258 1 3 5 8 14
367..................................... 584 3.1284 1 1 2 4 6
368..................................... 3136 6.4716 2 3 5 8 12
369..................................... 3178 3.2498 1 1 2 4 7
370..................................... 1151 5.9079 3 3 4 5 10
371..................................... 1368 3.6447 2 3 3 4 5
372..................................... 964 3.2811 1 2 2 3 5
373..................................... 3920 2.2487 1 2 2 3 3
374..................................... 130 3.0846 1 2 2 3 4
375..................................... 11 2.2727 1 2 2 2 4
376..................................... 249 3.0843 1 2 2 4 6
377..................................... 51 5.0392 1 1 4 6 12
378..................................... 158 2.4177 1 1 2 3 4
379..................................... 344 3.4506 1 1 2 4 6
380..................................... 60 2.0833 1 1 1 2 5
381..................................... 154 2.5065 1 1 1 3 5
382..................................... 45 1.2889 1 1 1 1 2
383..................................... 1746 3.6174 1 1 2 4 8
384..................................... 121 2.1488 1 1 1 2 4
385..................................... 1 1.0000 1 1 1 1 1
389..................................... 16 13.5000 1 3 6 11 24
390..................................... 14 4.0000 1 2 3 6 7
391..................................... 1 4.0000 4 4 4 4 4
392..................................... 2349 9.6841 3 4 7 12 20
394..................................... 1891 7.1364 1 2 4 8 16
395..................................... 87678 4.4004 1 2 3 6 9
396..................................... 15 4.6667 1 2 4 6 7
397..................................... 17705 5.1893 1 2 4 7 10
398..................................... 17713 5.9510 2 3 5 7 11
399..................................... 1727 3.5634 1 2 3 5 7
400..................................... 6490 9.1307 1 3 6 12 20
401..................................... 5622 11.2782 2 5 9 15 23
402..................................... 1500 4.0933 1 1 3 6 9
403..................................... 31997 8.0849 2 3 6 10 17
404..................................... 4670 4.2621 1 2 3 6 9
406..................................... 2527 9.9201 3 4 7 12 21
407..................................... 723 4.4219 1 2 4 5 8
408..................................... 2196 8.0255 1 2 5 10 18
409..................................... 2831 5.9325 2 3 4 6 12
410..................................... 33654 3.9062 1 2 4 5 6
411..................................... 13 2.3077 1 1 2 2 5
412..................................... 30 2.4000 1 1 2 3 4
413..................................... 6491 7.0875 2 3 5 9 14
414..................................... 782 4.2813 1 2 3 5 9
415..................................... 39080 14.3464 4 6 11 18 28
416..................................... 184735 7.3935 2 4 6 9 14
417..................................... 18 5.0000 1 2 4 7 9
418..................................... 23026 6.1212 2 3 5 7 11
419..................................... 15460 4.7254 2 2 4 6 9
420..................................... 3116 3.4881 1 2 3 4 6
421..................................... 11535 3.7877 1 2 3 5 7
422..................................... 83 3.0482 1 2 3 4 6
423..................................... 7539 8.1108 2 3 6 10 16
424..................................... 1308 13.6338 2 5 9 16 26
425..................................... 15852 3.9953 1 2 3 5 8
426..................................... 4552 4.4512 1 2 3 5 9
427..................................... 1669 4.6207 1 2 3 6 9
428..................................... 854 6.9859 1 2 4 8 14
429..................................... 26786 6.3438 2 3 5 7 12
430..................................... 59892 8.0207 2 3 6 10 16
431..................................... 319 6.4326 1 3 5 7 12
432..................................... 475 4.7684 1 2 3 5 9
433..................................... 5522 3.0996 1 1 2 4 6
439..................................... 1356 8.3857 1 3 5 10 18
440..................................... 5191 9.0326 2 3 6 11 20
441..................................... 604 3.2235 1 1 2 4 7
442..................................... 15588 8.4766 1 3 6 10 18
443..................................... 3743 3.4320 1 1 3 4 7
444..................................... 5303 4.1495 1 2 3 5 8
445..................................... 2450 2.8857 1 1 2 4 5
[[Page 40082]]
447..................................... 5497 2.4708 1 1 2 3 5
449..................................... 28365 3.7491 1 1 3 5 8
450..................................... 6934 1.9980 1 1 1 2 4
451..................................... 3 1.3333 1 1 1 2 2
452..................................... 22930 4.8560 1 2 3 6 10
453..................................... 5091 2.7969 1 1 2 3 5
454..................................... 4001 4.5431 1 2 3 5 9
455..................................... 939 2.5751 1 1 2 3 5
461..................................... 3676 4.3708 1 1 2 5 11
462..................................... 13083 11.2728 4 6 10 14 21
463..................................... 22068 4.1282 1 2 3 5 8
464..................................... 6542 3.0011 1 1 2 4 6
465..................................... 248 3.0202 1 1 2 4 6
466..................................... 1741 3.7030 1 1 2 4 8
467..................................... 1137 3.0633 1 1 2 3 6
468..................................... 55027 12.8995 3 6 10 16 26
471..................................... 11720 5.5506 3 4 4 6 9
473..................................... 7663 12.5910 1 3 7 18 32
475..................................... 107894 11.2229 2 5 9 15 22
476..................................... 4151 10.8829 2 5 9 14 21
477..................................... 25363 8.1252 1 3 6 11 17
478..................................... 108182 7.2900 1 3 5 9 15
479..................................... 24051 3.4569 1 1 3 4 7
480..................................... 562 20.9609 7 9 14 25 44
481..................................... 383 24.1253 10 18 22 27 39
482..................................... 5737 12.9796 4 7 10 15 25
483..................................... 42789 39.4482 14 22 33 49 71
484..................................... 331 13.0091 2 6 10 17 26
485..................................... 2959 9.7080 4 5 7 11 18
486..................................... 2017 12.4408 1 5 10 16 25
487..................................... 3506 7.3945 1 3 6 10 15
488..................................... 784 16.9031 3 7 12 22 36
489..................................... 14140 8.4372 2 3 6 10 17
490..................................... 5454 5.3577 1 2 4 6 11
491..................................... 12291 3.4475 2 2 3 4 6
492..................................... 2698 15.6675 3 5 8 25 34
493..................................... 55279 5.7576 1 3 5 7 11
494..................................... 30109 2.4447 1 1 2 3 5
495..................................... 159 15.0503 7 9 12 17 26
496..................................... 1504 9.7088 4 5 7 12 19
497..................................... 17585 6.5739 3 4 5 7 11
498..................................... 12931 4.1718 2 3 4 5 6
499..................................... 30519 4.7011 1 2 3 6 9
500..................................... 44330 2.6104 1 1 2 3 5
501..................................... 2200 10.9600 4 6 8 13 21
502..................................... 585 6.5692 3 4 5 8 11
503..................................... 5630 4.0014 1 2 3 5 7
504..................................... 118 30.5169 9 15 24 41 55
505..................................... 145 3.3517 1 1 1 3 7
506..................................... 931 17.4071 4 8 14 22 36
507..................................... 293 8.3379 2 4 7 11 18
508..................................... 671 7.4918 2 3 5 9 15
509..................................... 177 4.5367 1 2 4 6 9
510..................................... 1650 7.2358 2 3 5 9 15
511..................................... 608 4.8158 1 2 3 6 11
512..................................... 340 13.8971 7 8 11 16 25
513..................................... 115 10.6000 6 7 8 11 19
514..................................... 17025 7.8702 2 3 6 10 16
515..................................... 3788 5.9060 1 1 4 8 13
516..................................... 68886 4.7702 2 3 4 6 9
517..................................... 171423 2.6737 1 1 2 3 6
518..................................... 48733 3.5023 1 1 2 4 8
519..................................... 6359 5.1030 1 2 3 6 12
520..................................... 9489 2.1653 1 1 2 3 4
521..................................... 28014 5.9437 2 3 4 7 12
522..................................... 6852 9.4658 3 5 8 12 20
523..................................... 14954 4.0942 1 2 3 5 7
----------------
11094323
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 40083]]
Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) July 2001
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................... 0.343 0.410
ALASKA................................................ 0.417 0.697
ARIZONA............................................... 0.355 0.493
ARKANSAS.............................................. 0.466 0.445
CALIFORNIA............................................ 0.339 0.432
COLORADO.............................................. 0.422 0.577
CONNECTICUT........................................... 0.497 0.506
DELAWARE.............................................. 0.511 0.450
DISTRICT OF COLUMBIA.................................. 0.421 .......
FLORIDA............................................... 0.351 0.370
GEORGIA............................................... 0.461 0.469
HAWAII................................................ 0.412 0.549
IDAHO................................................. 0.541 0.561
ILLINOIS.............................................. 0.404 0.501
INDIANA............................................... 0.524 0.533
IOWA.................................................. 0.486 0.613
KANSAS................................................ 0.415 0.637
KENTUCKY.............................................. 0.479 0.492
LOUISIANA............................................. 0.401 0.491
MAINE................................................. 0.614 0.540
MARYLAND.............................................. 0.759 0.819
MASSACHUSETTS......................................... 0.511 0.571
MICHIGAN.............................................. 0.459 0.563
MINNESOTA............................................. 0.493 0.592
MISSISSIPPI........................................... 0.452 0.446
MISSOURI.............................................. 0.404 0.475
MONTANA............................................... 0.537 0.588
NEBRASKA.............................................. 0.448 0.610
NEVADA................................................ 0.306 0.503
NEW HAMPSHIRE......................................... 0.549 0.585
NEW JERSEY............................................ 0.394 .......
NEW MEXICO............................................ 0.466 0.491
NEW YORK.............................................. 0.524 0.607
NORTH CAROLINA........................................ 0.517 0.463
NORTH DAKOTA.......................................... 0.620 0.655
OHIO.................................................. 0.500 0.568
OKLAHOMA.............................................. 0.409 0.492
OREGON................................................ 0.614 0.598
PENNSYLVANIA.......................................... 0.398 0.526
PUERTO RICO........................................... 0.486 0.584
RHODE ISLAND.......................................... 0.510 .......
SOUTH CAROLINA........................................ 0.440 0.463
SOUTH DAKOTA.......................................... 0.529 0.640
TENNESSEE............................................. 0.438 0.453
TEXAS................................................. 0.401 0.493
UTAH.................................................. 0.497 0.582
VERMONT............................................... 0.572 0.599
VIRGINIA.............................................. 0.459 0.496
WASHINGTON............................................ 0.582 0.639
WEST VIRGINIA......................................... 0.568 0.527
WISCONSIN............................................. 0.524 0.613
WYOMING............................................... 0.523 0.717
------------------------------------------------------------------------
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) July 2001
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA........................................................ 0.044
ALASKA......................................................... 0.058
ARIZONA........................................................ 0.038
ARKANSAS....................................................... 0.049
CALIFORNIA..................................................... 0.034
COLORADO....................................................... 0.045
CONNECTICUT.................................................... 0.036
DELAWARE....................................................... 0.051
DISTRICT OF COLUMBIA........................................... 0.035
FLORIDA........................................................ 0.043
GEORGIA........................................................ 0.051
HAWAII......................................................... 0.038
IDAHO.......................................................... 0.046
ILLINOIS....................................................... 0.040
INDIANA........................................................ 0.056
IOWA........................................................... 0.049
KANSAS......................................................... 0.050
KENTUCKY....................................................... 0.046
LOUISIANA...................................................... 0.047
MAINE.......................................................... 0.040
MARYLAND....................................................... 0.013
MASSACHUSETTS.................................................. 0.053
MICHIGAN....................................................... 0.044
MINNESOTA...................................................... 0.047
MISSISSIPPI.................................................... 0.044
MISSOURI....................................................... 0.044
MONTANA........................................................ 0.053
NEBRASKA....................................................... 0.054
NEVADA......................................................... 0.030
NEW HAMPSHIRE.................................................. 0.061
NEW JERSEY..................................................... 0.036
NEW MEXICO..................................................... 0.045
NEW YORK....................................................... 0.051
NORTH CAROLINA................................................. 0.046
NORTH DAKOTA................................................... 0.074
OHIO........................................................... 0.047
OKLAHOMA....................................................... 0.046
OREGON......................................................... 0.046
PENNSYLVANIA................................................... 0.039
PUERTO RICO.................................................... 0.045
RHODE ISLAND................................................... 0.029
SOUTH CAROLINA................................................. 0.046
SOUTH DAKOTA................................................... 0.059
TENNESSEE...................................................... 0.048
TEXAS.......................................................... 0.046
UTAH........................................................... 0.047
VERMONT........................................................ 0.052
VIRGINIA....................................................... 0.055
WASHINGTON..................................................... 0.063
WEST VIRGINIA.................................................. 0.045
WISCONSIN...................................................... 0.051
WYOMING........................................................ 0.065
------------------------------------------------------------------------
Appendix A--Regulatory Impact Analysis
I. Introduction
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601
through 612), unless we certify that a final rule would not have a
significant economic impact on a substantial number of small entities.
For purposes of the RFA, we consider all hospitals to be small
entities. We estimate the total impact of these changes for FY 2002
payments compared to FY 2001 payments to be approximately a $1.9
billion increase. As such, this final rule is a major rule as defined
in 5 U.S.C. 804(2). Therefore, we have prepared an impact analysis for
this final rule.
Also, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis for any final rule that may have a
significant impact on the operations of a substantial number of small
rural hospitals. Such an analysis must conform to the provisions of
section 603 of the RFA. 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 systems, 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.
We have reviewed this final rule under the threshold criteria of
Executive Order 13132, Federalism, and have determined that the final
rule will not have any negative impact on the rights, roles, and
responsibilities of State, local, or tribal governments.
Section 202 of the Unfunded Mandate Reform Act of 1995 (Public Law
104-4) also requires that agencies assess anticipated costs and
benefits before issuing any final rule that has been preceded by a
final rule that may result in an expenditure in any one year by State,
local, or tribal governments, in the aggregate, or by the private
sector, of $110 million. This final rule would not mandate any
requirements for State, local, or tribal governments.
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 inpatient prospective payment system and
hospitals and units excluded from the system have both risen by 0.2
percentage points. As a result, the updates are 0.2 percentage points
higher than the updates reflected in the impact analysis for the
proposed rule. With the exception of these changes, we are generally
implementing the policy and
[[Page 40084]]
statutory provisions discussed in the proposed rule.
III. Impact Analysis for CMS-1131-F and CMS-1178-F
As noted previously, this final rule contains provisions
implemented in two interim final rules with comment periods. The first,
published August 1, 2000 (65 FR 47026), implemented, or conformed the
regulations to, certain statutory provisions relating to Medicare
payments to hospitals for inpatient services that were contained in
Public Law 106-113. The second, published June 13, 2001 (66 FR 32172),
implemented, or conformed the regulations to, certain statutory
provisions relating to Medicare payments to hospitals for inpatient
services that were contained in Public Law 106-554.
As described in the preamble to this final rule, with the exception
of minor changes to the process for receiving, reviewing, and approving
new Medicare-dependent small rural hospitals (MDHs), we are not
changing the policies described in those interim final rules with
comment period. Therefore, the reader should refer to the impact
analyses contained in those interim final rules for a discussion of the
impacts of these changes. For the impact analysis in the August 1, 2000
interim final rule, the reader should refer to page 47043. For the
impact analysis in the June 13, 2001 interim final rule, the reader
should refer to page 32184.
IV. Limitations of Our Analysis
As has been the case in our previously published regulatory impact
analyses, the following quantitative analysis presents the projected
effects of our proposed policy changes, including statutory changes
effective for FY 2002, 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
two comments on the impact analysis for our May 4, 2001 proposed rule.
Comment: One commenter, who was unable to reconcile the
standardized amounts for FY 2002 proposed in the May 4, 2001 Federal
Register with the standardized amounts published for FY 2001 (65 FR
47126 and 66 FR 32176), expressed concern with the level of detail
provided by the impact analysis and requested a breakdown of the
changes reflected in Column 8 of Table 1. The commenter also requested
that we release the complete data so that hospitals could evaluate all
the proposed FY 2002 policy changes on their own.
Response: As we stated in the proposed rule, column 8 compares our
estimate of payments per case, incorporating all changes reflected in
this final rule for FY 2002 (including statutory changes), to our
estimate of payments per case in FY 2001. It includes the effects of
the 2.75 percent update to the standardized amounts and the hospital-
specific rates for MDHs and SCHs. It also reflects the 1.1 percentage
point difference between the projected percentage of outlier payments
in FY 2001 (5.1 percent of total DRG payments) and the current estimate
of the percentage of actual outlier payments in FY 2001 (6.2 percent),
as described in the introduction to this Appendix and the Addendum to
this final rule. Additionally, there are differences resulting from the
increased number of hospitals receiving DSH payments under Section 211
of Public Law 106-554 and from the increase in SCH rebasing to a 1996
blended rate. There are also interactive effects among the various
factors comprising the payment system that we are not able to isolate.
For these reasons, the values in column 7 may not equal the sum of the
changes in columns 5 and 6, plus the other impacts that we are able to
identify. Since we explain the update for FY 2002 in section II. of the
Addendum of this final rule, and since the impact of those changes are
the same for all types of hospitals, we do not believe it is necessary
to isolate that change in a separate impact column. Also, we would like
to note that all of the data used by us in the impact analysis are
available to the public. Our impact file is posted on our website
following the publication of each proposed and final rule. For
information on obtaining the MedPAR file, the Provider-Specific File,
and the cost report files on which all of our analysis is based, we
refer the reader to section VIII. of this final rule.
Comment: One commenter noted that, in the proposed rule, the budget
neutrality factor in footnote 6 of Table 1 was printed as 0.992394
while the same factor was printed as 0.992493 on page 22872 and asked
which factor was correct.
Response: Footnote 6 to Table 1 in the proposed rule contained a
typographical error. The budget neutrality factor used in the proposed
rule was 0.992493 and was printed correctly on page 22872 of the
proposed rule.
V. Hospitals Included in and Excluded From the Prospective Payment
System
The prospective payment systems for hospital inpatient operating
and capital-related costs encompass nearly all general, short-term,
acute care hospitals that participate in the Medicare program. There
were 48 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. We also exclude
critical access hospitals (CAHs) from our analysis, due to the special
characteristics of these hospitals. Among other short-term, acute care
hospitals, only the 68 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 2001, we have included 4,795 hospitals in
our analysis. This represents about 80 percent of all Medicare-
participating hospitals. The majority of this impact analysis focuses
on this set of hospitals.
The remaining 20 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.
VI. Impact on Excluded Hospitals and Units
As of July 2001, there were 1,064 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 507 psychiatric, 210 rehabilitation, 260
long-term care, 77 children's, and 10 cancer hospitals. In addition,
there were 1,446 psychiatric units and 926 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 rate-of-increase ceiling is not applicable
to the 68 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
[[Page 40085]]
hospitals and units for FY 2002 would be between 0.8 and 3.3 percent,
or 0 percent, depending on the hospital's or unit's costs in relation
to its limit for the most recent cost reporting period for which
information is available.
The impact on excluded hospitals and units of the update in the
rate-of-increase limit depends on the cumulative cost increases
experienced by each excluded hospital or unit since its applicable base
period. For excluded hospitals and units that have maintained their
cost increases at a level below the percentage increases in the rate-
of-increase limits since their base period, the major effect will be on
the level of incentive payments these hospitals and units receive.
Conversely, for excluded hospitals and units with per-case cost
increases above the cumulative update in their rate-of-increase limits,
the major effect will be the amount of excess costs that would not be
reimbursed.
We note that, under Sec. 413.40(d)(3), an excluded hospital or unit
whose costs exceed 110 percent of its rate-of-increase limit receives
its rate-of-increase limit plus 50 percent of the difference between
its reasonable costs and 110 percent of the limit, not to exceed 110
percent of its limit. In addition, under the various provisions set
forth in Sec. 413.40, certain excluded hospitals and units can obtain
payment adjustments for justifiable increases in operating costs that
exceed the limit. At the same time, however, by generally limiting
payment increases, we continue to provide an incentive for excluded
hospitals and units to restrain the growth in their spending for
patient services.
VII. Graduate Medical Education Impact
A. National Average Per Resident Amount (PRA)
As discussed in detail in section IV.H.2. of this proposed rule, we
proposed to implement section 511 of Public Law 106-554, which
increased the floor of the locality-adjusted national average (PRA for
the purposes of computing direct GME payments for cost reporting
periods beginning during FY 2002. The national average PRA payment
methodology, as provided in section 311 of Public Law 106-113,
establishes a ``floor'' and ``ceiling'' based on a locality-adjusted,
updated national average PRA for cost reporting periods beginning on or
after October 1, 2000 and before October 1, 2005. Section 511 of Public
Law 106-554 increased the floor from 70 percent to equal 85 percent of
a locality-adjusted national average PRA for FY 2002.
For this final rule, we have calculated an estimated impact of this
policy on teaching hospitals' PRAs for FY 2002, making assumptions
about update factors and geographic adjustment factors (GAF) for each
hospital. Generally, using FY 1997 data, we calculated a floor based on
70 percent of the national average PRA and a floor based on 85 percent
of the national average PRA. We then determined the amount of direct
GME payments that would have been paid had the floor remained at 70
percent of the national average PRA. Next, we determined the amount of
direct GME payments that would be paid with the floor increased to
equal 85 percent of the national average PRA. We subtracted the
difference between the two and inflated the difference to FY 2002 to
determine the impact of this provision.
The figures we used in this impact, except for the FY 1997 weighted
PRA of $68,464, are estimations and are for demonstrative purposes
only. Hospitals must use the methodology stated in section IV.H. of
this final rule to revise (if appropriate) their individual PRAs.
In calculating this impact, we used Medicare cost report data for
all cost reports ending in FY 1997. We excluded hospitals that file
manual cost reports because we did not have access to their Medicare
utilization data. We also excluded all teaching hospitals in Maryland,
because these hospitals are paid on a Medicare waiver outside of the
prospective payment system, and those hospitals' PRAs do not determine
their level of direct GME payments. For hospitals that had two cost
reporting periods ending in FY 1997, we used the later of the two
periods. A total of 1,231 teaching hospitals were included in the
analysis.
Using the FY 1997 weighted average PRA of $68,464, we determined an
85 percent floor of $58,194 for FY 1997. We then determined that, for
cost reporting periods ending in FY 1997, approximately 562 hospitals
had PRAs that were below $58,194 (336 hospitals of these hospitals had
PRAs that were below the 70-percent floor, and 226 hospitals had PRAs
that were above the 70-percent floor but below the 85-percent floor).
The estimated total cost to the Medicare program in FY 2002 of
replacing the PRAs of the 562 hospitals with the 85-percent floor is
$105.3 million.
B. Closed Training Programs or Hospitals That Close Their Training
Programs
As discussed in IV.H.5, of the preamble of this final rule, we are
allowing a hospital to receive a temporary adjustment to its FTE cap to
reflect residents added because of the closure of another hospital's
GME program if the hospital that closed its program agrees to
temporarily reduce its FTE cap. We have calculated an estimated impact
on the Medicare program for FY 2002 as a result of this policy. We used
the best available cost report data from the FY 1997 HCRIS in our
analysis.
We estimate that approximately 5 to 10 programs, each with an
average of 25 residents, close each year without advance warning,
displacing the residents before they complete their training.
Therefore, the number of residents displaced each year could be between
125 and 250. We estimated the impact of this change based on direct GME
and IME payment amounts in FY 1997 to determine a total GME amount and
updated the total with the CPI-U for FY 2002. At most, the estimated
impact for this provision for FY 2002 is moving payments of between $10
and $20 million among different hospitals. This would result from
redirecting these payments from the hospital that closed its program to
the hospital(s) that takes on the residents.
VIII. Quantitative Impact Analysis of the Final 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
final 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 March 2001 update of the FY 2000 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 final policy changes. Second, due to the
[[Page 40086]]
interdependent nature of the prospective payment system, it is very
difficult to precisely quantify the impact associated with each final
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 sources overall. For individual hospitals, however,
some miscategorizations are possible.
Using cases from the March, 2001 update of the FY 2000 MedPAR file,
we simulated payments under the operating prospective payment system
given various combinations of payment parameters. Any short-term, acute
care hospitals not paid under the general prospective payment systems
(Indian Health Service hospitals and hospitals in Maryland) are
excluded from the simulations. Payments under the capital prospective
payment system, or payments for costs other than inpatient operating
costs, are not analyzed here. Estimated payment impacts of FY 2002
policy changes to the capital prospective payment system are discussed
in section IX. of this Appendix.
The changes discussed separately below are the following:
The effects of the annual reclassification of diagnoses
and procedures and the recalibration of the diagnosis-related group
(DRG) relative weights required by section 1886(d)(4)(C) of the Act.
The effects of changes in hospitals' wage index values
reflecting wage data from hospitals' cost reporting periods beginning
during FY 1998, compared to the FY 1997 wage data.
The effects of our final policy to increase the accuracy
of the wage index calculation by changing the overhead allocation
method used so that the salaries and hours of lower-wage, overhead
employees and the overhead wage-related costs associated with the
excluded areas of the hospital are more accurately removed when
calculating the overhead costs attributable to wages.
The effects of our final policy to include the contract
labor costs of laboratories and pharmacies from Worksheet S-3 Part II
Lines 9.01 and 9.02 in the wage index calculation.
The combined effects of our changes to the wage index data
and calculations and the changes in the DRG recalibration.
The effects of geographic reclassifications by the
Medicare Geographic Classification Review Board (MGCRB) that will be
effective in FY 2002.
The effects of our new policy to hold-harmless other
hospitals in an urban area where certain hospitals are reclassified
elsewhere by including the wage data of reclassified hospitals in their
geographic area as well as the area to which they are reclassified.
The total change in payments based on FY 2002 policies
relative to payments based on FY 2001 policies.
To illustrate the impacts of the FY 2002 final changes, our
analysis begins with a FY 2002 baseline simulation model using: the FY
2001 DRG GROUPER (version 18.0); the FY 2001 wage index; 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 2002 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 2001 to FY 2002. Five 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, as amended by
section 301 of Public Law 106-554, we updated the large urban and the
other areas average standardized amounts for FY 2002 using the most
recently forecasted hospital market basket increase for FY 2002 of 3.3
percent minus 0.55 percentage points (for an update of 2.75 percent).
Under section 1886(b)(3) of the Act, the updates to the hospital-
specific amounts for sole community hospitals (SCHs) and for MDHs are
equal to the market basket increase of 3.3 percent minus 0.55
percentage points (for an update of 2.75 percent).
A second significant factor that impacts changes in hospitals'
payments per case from FY 2001 to FY 2002 is the change in MGCRB status
from one year to the next. That is, hospitals reclassified in FY 2001
that are no longer reclassified in FY 2002 may have a negative payment
impact going from FY 2001 to FY 2002; conversely, hospitals not
reclassified in FY 2001 that are reclassified in FY 2002 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 change in payments
for the category may be below the national mean. This effect may be
alleviated somewhat by section 304(a) of Public Law 106-554, which
provided that reclassifications for purposes of the wage index are for
a 3 year period.
A third significant factor is that we currently estimate that
actual outlier payments during FY 2001 will be 6.2 percent of actual
total DRG payments. When the FY 2001 final rule was published, we
projected FY 2001 outlier payments would be 5.1 percent of total DRG
plus outlier payments; the standardized amounts were offset
correspondingly. The effects of the higher than expected outlier
payments during FY 2001 (as discussed in the Addendum to this final
rule) are reflected in the analyses below comparing our current
estimates of FY 2001 payments per case to estimated FY 2002 payments
per case.
Fourth, section 213 of Public Law 106-554 provided that all SCHs
may receive payment on the basis of their costs per case during their
cost reporting period that began during 1996. For FY 2002, eligible
SCHs that are rebased receive a hospital-specific rate comprised of the
greater of 50-percent of the higher of their FY 1982 or FY 1987
hospital-specific rate or 50-percent of the federal rate, and 50-
percent of their FY 1996 hospital-specific rate.
Fifth, sections 302 and 303 of Public Law 106-554 affect payments
for indirect medical education (IME) and disproportionate share
hospitals (DSH), respectively. These sections increased IME and DSH
payments during FY 2001 (effective with discharges on or after April 1,
2001). For FY 2002, section 302 established IME payments at the same
level as FY 2001 (6.5 percent), and section 303 established DSH
payments at the adjustment the hospital would otherwise receive minus 3
percent.
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 4,795 hospitals included in the analysis. This number is 93
fewer hospitals than were included in the impact analysis in the FY
2001 final rule (65 FR 47191).
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) and rural). There are 2,704
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,561 hospitals located in large urban
areas (populations over 1 million), and 1,143 hospitals in other urban
areas (populations of 1 million or fewer). In
[[Page 40087]]
addition, there are 2,091 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 2002 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 2,746, 1,632, 1,114,
and 2,049, 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 3,668
non-teaching hospitals in our analysis, 890 teaching hospitals with
fewer than 100 residents, and 237 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.)
We note that section 211 of Public Law 106-554 reduced the qualifying
DSH threshold to 15 percent for all hospitals (this threshold
previously applied to urban hospitals with 100 or more beds and rural
hospitals with 500 or more beds). Consequently, many more hospitals
qualify for DSH. In the FY 2001 final rule, there were 3,070 hospitals
that did not receive a DSH adjustment (65 FR 47192). In Table I, the
number of hospitals that did not receive a DSH adjustment declines to
1,879. The number of urban hospitals with fewer than 100 beds receiving
DSH increases from 72 prior to section 211 to 316 after its
implementation. Among rural hospitals with fewer than 100 beds, 103
received DSH prior to section 211; for FY 2002 that number increases to
454.
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 (165), SCHs (680), MDHs (329), and SCH
and RRCs (70) shown here were not reclassified for purposes of the
standardized amount. There are 15 RRCs, 1 MDH, 4 SCHs, and 1 SCH and
RRC that will be reclassified as urban for the standardized amount in
FY 2002 and, 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 1999 Medicare cost
report files, if available (otherwise FY 1998 data are used). Data
needed to determine ownership status or Medicare utilization
percentages were unavailable for 52 and 78 hospitals, respectively. For
the most part, these appear to be new hospitals, without cost reports
on file for FY 1999.
The next series of groupings concern the geographic
reclassification status of hospitals. The first grouping displays all
hospitals that were reclassified by the MGCRB for FY 2002. The next two
groupings separate the hospitals in the first group by urban and rural
status. The final row in Table I contains hospitals located in rural
counties but deemed to be urban under section 1886(d)(8)(B) of the Act.
Table I.--Impact Analysis of Changes For FY 2002 Operating Prospective Payment System
[Percent changes in payments per case]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Reclassi-
New Include MCGRB fication All FY
Num. of DRG re- New wage overhead contract DRG & WI reclassi- hold- 2002
hosps. calib.\2\ data \3\ alloc.\4\ labor \5\ changes fication harmless changes
\1\ \6\ \7\ policy \9\
(0) (1) (2) (3) (4) (5) (6) (7) (8)
--------------------------------------------------------------------------------------------------------------------------------------------------------
By Geographic Location
All hospitals.................................... 4,795 0.3 0.2 -0.1 -0.1 0.0 -0.2 0.2 2.1
Urban hospitals................................ 2,704 0.3 0.2 -0.1 -0.1 0.0 -0.7 0.2 1.9
Large urban areas(populations over 1 million) 1,561 0.4 0.0 -0.1 -0.1 -0.1 -0.8 0.3 1.8
Other urban areas (populations of 1 million 1,143 0.2 0.5 -0.2 -0.1 0.2 -0.5 0.1 2.0
or fewer)...................................
Rural hospitals.............................. 2,091 0.0 0.0 0.2 0.2 -0.2 2.6 0.0 3.4
Bed Size (Urban):
0-99 beds.................................... 695 -0.1 0.1 0.1 0.1 0.0 -0.8 0.2 2.6
100-199 beds................................. 948 0.3 -0.1 0.2 0.2 0.0 -0.7 0.3 2.1
200-299 beds................................. 529 0.3 0.2 0.0 0.0 0.1 -0.7 0.3 2.0
300-499 beds................................. 383 0.3 0.4 -0.3 -0.2 0.0 -0.7 0.2 1.8
500 or more beds............................. 149 0.5 0.4 -0.4 -0.4 0.0 -0.6 0.1 1.6
Bed Size (Rural):
0-49 beds.................................... 1,226 -0.2 0.1 0.2 0.1 -0.3 0.3 0.0 3.4
50-99 beds................................... 520 -0.1 0.0 0.2 0.1 -0.3 1.0 0.0 3.5
100-149 beds................................. 203 0.0 0.0 0.3 0.2 -0.1 3.3 0.1 3.4
150-199 beds................................. 75 0.1 -0.2 0.2 0.2 -0.2 5.2 0.0 3.6
200 or more beds............................. 67 0.1 -0.1 0.1 0.1 -0.2 4.8 0.0 3.3
Urban by Region:
New England.................................. 138 0.3 1.6 -0.3 -0.2 1.2 -0.3 0.2 3.0
Middle Atlantic.............................. 416 0.4 -0.5 0.0 0.1 -0.4 -0.7 0.6 1.3
South Atlantic............................... 393 0.4 0.5 -0.1 -0.1 0.4 -0.8 0.3 2.4
East North Central........................... 459 0.2 0.1 -0.2 -0.2 -0.3 -0.5 0.1 1.7
East South Central........................... 160 0.3 1.0 -0.1 -0.1 0.8 -0.7 0.0 3.0
West North Central........................... 187 0.2 0.4 -0.3 -0.3 -0.1 -0.7 0.0 1.7
West South Central........................... 340 0.3 -0.2 -0.2 -0.1 -0.4 -0.7 0.0 1.3
Mountain..................................... 136 0.2 0.8 -0.3 -0.3 0.3 -0.7 0.0 2.2
Pacific...................................... 429 0.5 0.0 0.1 0.1 0.1 -0.8 0.3 1.9
[[Page 40088]]
Puerto Rico.................................. 46 0.1 2.1 -0.8 -0.9 1.1 -0.8 0.2 3.3
Rural by Region:
New England.................................. 50 0.0 0.0 0.1 0.1 -0.3 2.9 0.0 3.7
Middle Atlantic.............................. 75 0.1 0.1 0.1 0.1 -0.1 2.3 0.0 3.2
South Atlantic............................... 269 0.1 -0.1 0.2 0.2 -0.2 2.9 0.0 3.6
East North Central........................... 276 -0.2 0.0 0.1 0.2 -0.4 2.2 0.0 2.9
East South Central........................... 263 0.0 -0.1 0.2 0.2 -0.2 3.2 0.0 3.7
West North Central........................... 481 -0.3 0.3 0.2 0.1 -0.1 1.8 0.0 2.6
West South Central........................... 333 0.0 0.3 0.2 0.2 0.1 3.6 0.0 4.8
Mountain..................................... 195 0.0 -0.1 0.2 0.1 -0.3 1.7 0.0 3.0
Pacific...................................... 144 0.1 -0.9 0.2 0.2 -0.9 2.3 0.0 2.8
Puerto Rico.................................. 5 -0.3 6.1 0.2 0.1 5.6 -0.7 0.2 9.9
By Payment Classification:
Urban hospitals.............................. 2,746 0.3 0.2 -0.1 -0.1 0.0 -0.6 0.2 1.9
Large urban hospitals (populations over 1 1,632 0.4 0.0 -0.1 -0.1 -0.1 -0.7 0.3 1.9
million)....................................
Other urban hospitals (populations of 1 1,114 0.2 0.5 -0.2 -0.1 0.2 -0.5 0.1 2.0
million or fewer)...........................
Rural hospitals.............................. 2,049 0.0 0.0 0.2 0.2 -0.2 2.4 0.0 3.4
Teaching Status:...............................
Non-teaching................................. 3,668 0.1 0.0 0.2 0.2 0.0 0.2 0.2 2.4
Fewer than 100 Residents..................... 890 0.2 0.4 -0.2 -0.1 0.1 -0.6 0.2 2.0
100 or more Residents........................ 237 0.6 0.3 -0.5 -0.4 0.0 -0.5 0.1 1.7
Urban DSH:
Non DSH........................................ 1,879 0.1 0.2 -0.1 -0.1 -0.1 -0.1 0.2 1.9
100 or more beds............................... 1,379 0.4 0.2 -0.1 -0.1 0.1 -0.7 0.2 1.9
Less than 100 beds............................. 316 0.1 -0.1 0.3 0.3 0.0 -0.7 0.2 4.0
Rural DSH:
Sole Community (SCH)......................... 545 0.0 0.0 0.1 0.1 -0.3 0.3 0.0 3.1
Referral Center (RRC)........................ 152 0.2 -0.1 0.2 0.2 -0.1 5.2 0.0 3.8
Other Rural:
100 or more beds............................. 70 0.0 0.1 0.3 0.3 0.1 1.5 0.1 3.7
Less than 100 beds........................... 454 -0.1 -0.1 0.2 0.2 -0.4 0.6 0.0 4.5
Urban teaching and DSH:
Both teaching and DSH........................ 758 0.5 0.3 -0.3 -0.2 0.1 -0.7 0.2 1.9
Teaching and no DSH.......................... 298 0.2 0.4 -0.3 -0.3 -0.1 -0.5 0.3 1.8
No teaching and DSH.......................... 937 0.3 0.0 0.2 0.2 0.1 -0.6 0.2 2.2
No teaching and no DSH....................... 753 0.1 -0.1 0.1 0.1 -0.1 -0.6 0.2 1.8
Rural Hospital Types:
Non-special status............................. 805 -0.2 0.0 0.3 0.2 -0.2 0.9 0.0 3.8
RRC............................................ 165 0.1 -0.1 0.2 0.2 -0.1 6.3 0.1 3.7
SCH............................................ 680 0.0 0.0 0.1 0.1 -0.3 0.3 0.0 2.7
Medicare-dependent hospitals (MDH)............. 329 -0.2 0.2 0.1 0.1 -0.2 0.4 0.0 3.6
SCH and RRC.................................... 70 0.0 0.0 0.1 0.1 -0.3 2.1 0.0 2.9
Type of Ownership:
Voluntary...................................... 2,765 0.3 0.1 -0.1 -0.1 -0.1 -0.3 0.2 2.0
Proprietary.................................... 717 0.3 0.1 0.0 0.0 0.1 0.0 0.1 2.4
Government..................................... 1,261 0.3 0.4 -0.1 0.0 0.3 0.0 0.0 0.0
Unknown........................................ 52 -0.4 0.6 0.1 0.1 -0.1 -1.8 1.0 1.6
Medicare Utilization as a Percent of Inpatient
Days:
0-25........................................... 396 0.7 0.2 0.0 0.0 0.5 -0.4 0.2 2.5
25-50.......................................... 1,886 0.4 0.2 -0.2 -0.2 0.0 -0.6 0.2 1.9
50-65.......................................... 1,843 0.1 0.2 0.0 0.0 0.0 0.1 0.2 2.4
Over 65........................................ 592 0.1 -0.2 0.2 0.2 -0.1 0.3 0.2 2.2
Unknown........................................ 78 0.3 -0.3 -0.1 0.0 -0.6 0.8 0.2 0.7
Hospitals Reclassified by the Medicare Geographic
Classification Review Board: FY 2002
Reclassifications:
All Reclassified Hospitals....................... 628 0.2 0.2 0.0 0.0 0.0 5.0 0.1 3.3
Standardized Amount Only....................... 74 0.1 -0.4 0.3 0.4 -0.3 2.2 0.4 3.8
Wage Index Only................................ 391 0.2 0.0 0.0 0.0 -0.1 5.5 0.1 2.8
Both........................................... 58 0.2 0.3 0.1 0.1 0.1 5.1 0.0 0.6
All Nonreclassified Hospitals.................. 4,246 0.3 0.2 -0.1 0.1 0.0 0.8 0.2 2.1
All Reclassified UrbanHospitals.................. 117 0.4 0.7 -0.3 -0.3 0.2 4.2 0.1 2.6
Standardized Amount Only....................... 14 0.2 -0.3 0.5 0.5 -0.1 0.4 0.3 2.6
Wage Index Only................................ 83 0.4 0.7 -0.5 -0.4 0.2 4.5 0.1 2.4
Both........................................... 20 0.2 0.7 0.2 0.3 0.8 4.7 0.5 3.5
Urban Nonreclassified Hospitals................ 2,549 0.3 0.2 -0.1 -0.1 0.0 -1.0 0.2 1.8
Reclassified Rural Hospitals..................... 511 0.1 0.0 0.2 0.2 -0.2 5.5 0.0 3.7
Standardized Amount Only....................... 16 0.0 -0.1 0.2 0.2 -0.3 3.8 0.0 2.3
Wage Index Only................................ 472 0.1 0.0 0.2 0.2 -0.2 5.3 0.0 3.7
Both........................................... 23 0.0 0.2 0.1 0.1 -0.1 9.3 0.0 4.0
Rural Nonreclassified Hospitals................ 1,577 -0.1 0.0 0.2 0.1 -0.3 -0.6 0.0 3.0
[[Page 40089]]
Other Reclassified Hospitals (Section 41 0.1 0.6 0.1 0.1 0.4 0.8 -0.7 4.2
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 2000, and hospital cost report data are from reporting periods beginning in FY 1999 and FY 1998.
\2\ This column displays the payment impact of the recalibration of the DRG weights based on FY 2000 MedPAR data and the DRG reclassification changes,
in accordance with section 1886(d)(4)(C) of the Act.
\3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1998 cost reports.
\4\ This column displays the impact of removing the salaries and hours of lower-wage, overhead employees and the overhead wage-related costs associated
with the excluded areas of the hospital from the wage index calculation.
\5\ This column displays the impact of including contract pharmacy and contract laboratory costs and hours in the wage index calculation.
\6\ This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate
the wage index, the revised overhead allocation, the laboratory and pharmacy contract labor costs, and the budget neutrality adjustment factor for
these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act. Thus, it represents the combined impacts shown in
columns 1, 2, 3, and 4, and the FY 2002 budget neutrality factor of .995821.
\7\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
the FY 2002 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2002. Reclassification for
prior years has no bearing on the payment impacts shown here.
\8\ Shown here are the effects of our policy to hold-harmless other hospitals in an urban area where certain hospitals are reclassified elsewhere by
including the wage data of reclassified hospitals in their geographic area as well as the area to which they are reclassified.
\9\ This column shows changes in payments from FY 2001 to FY 2002. It incorporates all of the changes displayed in columns 5, 6, and 7 (the changes
displayed in columns 1, 2, 3, and 4 are included in column 5). It also displays the impact of the FY 2002 update, changes in hospitals'
reclassification status in FY 2002 compared to FY 2001, and the difference in outlier payments from FY 2001 to FY 2002. It also reflects section 213
of Public law 106-554, which permitted all SCHs to rebase for a 1996 hospital-specific rate. The sum of these columns may be different from the
percentage changes shown here due to rounding and interactive effects.
B. Impact of the Final 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 2001 DRG relative
weights (GROUPER version 18) to aggregate payments using the final FY
2002 DRG relative weights (GROUPER version 19). Overall payments
increase 0.3 percent due to the DRG reclassification and recalibration.
We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we
have applied a budget neutrality factor to ensure that the overall
payment impact of the DRG (and wage index) changes is budget neutral.
This budget neutrality factor of 0.995821 is applied to payments in
Column 5.
We estimate that the DRG changes effective with this final rule
would result in higher payments to urban hospitals (0.3 percent) and
would have a 0 percent impact on payments to rural hospitals. The
changes also would result in higher payments to larger hospitals than
to smaller hospitals. This impact is consistent for both urban and
rural bed size groups.
This distributional impact likely results from the final changes to
major diagnostic category (MDC) 5 ``Diseases and Disorders of the
Circulatory System.'' As described in section II. of the preamble of
this final rule, we are removing cardiac defibrillator cases from DRGs
104 and 105, and creating two new DRGs for these cases. In addition, we
are revising the basis of the DRG assignment for cases involving
percutaneous transluminal coronary angioplasty based on whether the
patient experienced an acute myocardial infarction. Because MDC 5 is a
high volume category, refining the categorizations of these cases has a
noticeable overall payment impact.
C. Impact of Updating the Wage Data and the Final Changes to the Wage
Index Calculation (Columns 2, 3 & 4)
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 final wage index for FY
2002 is based on data submitted for hospital cost reporting periods
beginning on or after October 1, 1997 and before October 1, 1998. As
with column 1, the impact of the new data on hospital payments is
isolated in column 2 by holding the other payment parameters constant
in the two simulations. That is, column 2 shows the percentage changes
in payments when going from a model using the FY 2001 wage index (based
on FY 1997 wage data before geographic reclassifications to a model
using the FY 2002 prereclassification wage index based on FY 1998 wage
data).
The wage data collected on the FY 1998 cost reports are similar to
the data used in the calculation of the FY 2001 wage index. For a
thorough discussion of the data used to calculate the wage index, see
section III.B. of the preamble of this final rule. The July 30, 1999
final rule (64 FR 41505) indicated that we would phase-out costs
related to GME and certified registered nurse anesthestists (CRNA) from
the calculation of the wage index over a 5-year period, beginning in FY
2000. The FY 2001 wage index was based on a blend of 60 percent of an
average hourly wage including these costs, and 40 percent of an average
hourly wage excluding these costs. For FY 2002, the wage index is based
on a blend of 40 percent of an average hourly wage including these
costs, and 60 percent of an average hourly wage excluding these costs.
This change is reflected in column 2.
The results indicate that the new wage data are estimated to
provide a 0.2 percent increase for hospital payments overall (prior to
applying the budget neutrality factor, see column 5). In some cases,
the results shown in this final rule may be very different from the
impacts shown in the proposed rule. This is due to the large number of
data revisions submitted by hospitals after the proposed wage index was
calculated. Approximately 30 percent of hospitals submitted revisions
in the interim.
Rural hospitals are generally estimated to experience a negligible
[[Page 40090]]
impact from the new wage data, although rural hospitals in Puerto Rico
experience a 6.1 percent increase, likely due to the 13 percent
increase in the value of five providers' FY 2002 wage index compared to
the wage index for those same providers for FY 2001. Additionally,
rural hospitals in West North Central and West South Central experience
estimated wage index-driven increases of more than 0.3 percent.
Meanwhile, hospitals in the Pacific census division experience a 0.9
percent decrease.
Urban hospitals as a group are estimated to benefit positively from
the updated wage data. The other urban hospitals appear to experience a
0.5 percent increase and estimated payments to urban hospitals overall
showed an increase of 0.2 percent. Among urban census divisions, Puerto
Rico experiences a 2.1 percent increase, the New England division
experiences a 1.6 percent increase, East South Central experiences a
1.0 percent increase, and Middle Atlantic a 0.5 percent decrease.
Columns 3 and 4, respectively, show that the final change to the
overhead calculation and the policy to include contract labor costs in
the wage index discussed in detail in section III.C. of the preamble of
this final rule both appear to benefit rural hospitals and small
hospitals. Urban hospitals as a group are impacted by a 0.1 percent
decrease to their payments from each change. Rural hospitals are
expected to receive an estimated 0.2 percent increase in payments due
to this policy change.
The following chart compares the shifts in wage index values for
labor market areas for FY 2001 relative to FY 2002. This chart
demonstrates the impact of the final changes for the FY 2002 wage index
relative to the FY 2001 wage index. The majority of labor market areas
(335) experience less than a 5-percent change. A total of 28 labor
market areas experience an increase of more than 5 percent, with 2
having an increase greater than 10 percent. A total of 11 areas
experience decreases of more than 5-percent. Of those, 1 declines by
more than 10 percent.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values ---------------------
FY 2001 FY 2002
------------------------------------------------------------------------
Increase more than 10 percent..................... 1 2
Increase more than 5 percent and less than 10 20 26
percent..........................................
Increase or decrease less than 5 percent.......... 339 335
Decrease more than 5 percent and less than 10 14 10
percent..........................................
Decrease more than 10 percent..................... 1 1
------------------------------------------------------------------------
Among urban hospitals, 129 would experience an increase of between
5 and 10 percent, and 3 experience an increase of more than 10 percent.
A total of 18 rural hospitals have increases greater than 5 percent,
with 5 increasing greater than 10 percent. On the negative side, 29
urban hospitals have decreases in their wage index values of at least 5
percent but less than 10 percent. Four urban hospitals have decreases
in their wage index values greater than 10 percent. There are no rural
hospitals with decreases in their wage index values greater than 5
percent. The following chart shows the projected impact for urban and
rural hospitals.
------------------------------------------------------------------------
Number of hospitals
Percentage change in area wage index values ---------------------
Urban Rural
------------------------------------------------------------------------
Increase more than 10 percent..................... 3 5
Increase more than 5 percent and less than 10 129 13
percent..........................................
Increase or decrease less than 5 percent.......... 2,531 2,166
Decrease more than 5 percent and less than 10 29 0
percent..........................................
Decrease more than 10 percent..................... 4 0
------------------------------------------------------------------------
D. Combined Impact of DRG and Wage Index Changes-- Including Budget
Neutrality Adjustment (Column 5)
The impact of DRG reclassifications and recalibration on aggregate
payments is required by section 1886(d)(4)(C)(iii) of the Act to be
budget neutral. In addition, section 1886(d)(3)(E) of the Act specifies
that any updates or adjustments to the wage index are to be budget
neutral. As noted in the Addendum to this final rule, we compared
simulated aggregate payments using the FY 2001 DRG relative weights and
wage index to simulated aggregate payments using the final FY 2002 DRG
relative weights and wage index. Based on this comparison, we computed
a wage and recalibration budget neutrality factor of 0.995821. In Table
I, the combined overall impacts of the effects of both the DRG
reclassifications and recalibration and the updated wage index are
shown in column 5. The 0.0 percent impact for all hospitals
demonstrates that these changes, in combination with the budget
neutrality factor, are budget neutral.
For the most part, the changes in this column are the sum of the
changes in columns 1, 2, 3 and 4, minus approximately 0.4 percent
attributable to the budget neutrality factor. There may be some
variation of plus or minus 0.1 percent due to rounding.
E. Impact of MGCRB Reclassifications (Columns 6 & 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 5 reflect the per case
payment impact of moving from this baseline to a simulation
incorporating the MGCRB decisions for FY 2002. As noted below, these
decisions may affect hospitals' standardized amount and wage index area
assignments. The changes in column 7 reflect the postreclassified wage
index values resulting from including the wage data for a reclassified
hospital in both the area to
[[Page 40091]]
which it is reclassified and the area where the hospital is physically
located.
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. 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.
The final FY 2002 wage index values incorporate all of the MGCRB's
reclassification decisions for FY 2002. The wage index values also
reflect any decisions made by the CMS Administrator through the appeals
and review process for MGCRB decisions.
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 0.990675 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4.b. of the
Addendum to this final rule.) This results in a larger budget
neutrality offset than the FY 2001 factor of 0.993187. This larger
offset is accounted for by the extension of wage index
reclassifications for 3 years as a result of section 304 of Public Law
106-554, and our final policy to hold-harmless the calculation of urban
areas' wage indexes for reclassifications out of the area (see column
7). We have identified 162 hospitals that were reclassified for FY
2001, but not FY 2002, that will nonetheless continue to be
reclassified due to section 304 of Public Law 106-554.
As a group, rural hospitals benefit from geographic
reclassification. Their payments rise 2.6 percent in column 6. Payments
to urban hospitals decline 0.7 percent. Hospitals in other urban areas
see a decrease in payments of 0.5 percent, while large urban hospitals
lose 0.8 percent. Among urban hospital groups (that is, bed size,
census division, and special payment status), payments generally
decline.
A positive impact is evident among most of the rural hospital
groups. The largest increases are in the West South Central, East South
Central, New England and the South Atlantic regions. These regions
receive increases of 3.6, 3.2, and 2.9 and 2.9, respectively. The rural
census division for the Puerto Rico region appears to receive an
estimated decrease in payments of 0.7 percent.
Among all the hospitals that were reclassified for FY 2002, the
MGCRB changes are estimated to provide a 5.0 percent increase in
payments. Urban hospitals reclassified for FY 2002 are anticipated to
receive an increase of 4.2 percent, while rural reclassified hospitals
are expected to benefit from the MGCRB changes with a 5.5 percent
increase in payments. Overall, among hospitals that were reclassified
for purposes of the standardized amount only, a payment increase of 2.2
percent is expected, while those reclassified for purposes of the wage
index only show a 5.5 percent increase in payments. Payments to urban
hospitals that did not reclassify are expected to decrease by 1.0
percent due to the budget neutrality of MGCRB changes. Those hospitals
located in rural counties but deemed to be urban under section
1886(d)(8)(B) of the Act are expected to receive an increase in
payments of 0.1 percent.
Column 7 shows the impacts of our final policy to include the wage
data for a reclassified hospital in both the area to which it is
reclassified and the area where the hospital is physically located.
This change affects overall payments by 0.2 percent, partially
accounting for the larger budget neutrality factor compared to FY 2001.
The payment impacts are generally largest in urban hospital groups,
with the largest impact, 0.6 percent, experienced by urban hospitals in
the Middle Atlantic census division.
F. All Changes (Column 8)
Column 8 compares our estimate of payments per case, incorporating
all changes reflected in this final rule for FY 2002 (including
statutory changes), to our estimate of payments per case in FY 2001. It
includes the effects of the 2.75 percent update to the standardized
amounts and the hospital-specific rates for MDHs and SCHs. It also
reflects the 1.1 percentage point difference between the projected
percentage of outlier payments in FY 2001 (5.1 percent of total DRG
payments) and the current estimate of the percentage of actual outlier
payments in FY 2001 (6.2 percent), as described in the introduction to
this Appendix and the Addendum to this final rule.
We also note that section 211 of Public Law 106-554 changed the
criteria for hospitals to qualify for DSH payment status. Since more
hospitals are now eligible to receive DSH payments for the full FY
2002, as opposed to for just the second 6 months of FY 2001, DSH
payments to providers in FY 2002 would increase and this change is also
captured in column 8.
Section 213 of Public Law 106-554 provided that all SCHs may elect
to receive payment on the basis of their costs per case during their
cost reporting period that began during 1996. For FY 2002, eligible
SCHs that rebase receive a hospital-specific rate comprised of 50
percent of the higher of their FY 1982 or FY 1987 hospital-specific
rate or their Federal rate, and 50 percent of their 1996 hospital-
specific rate. The impact of this provision is modeled in column 8 as
well.
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 5, 6, and 7, plus the other impacts that we are able
to identify.
Hospitals in urban areas experience a 1.9 percent increase in
payments per case compared to FY 2001. The net 0.5 percent negative
impact due to reclassification (columns 6 and 7) is offset by a similar
negative impact for FY 2001 of 0.4 percent (65 FR 47196). Hospitals in
rural areas, meanwhile, experience a 3.4 percent payment increase. This
is primarily due to the change in the DSH threshold to 15 percent for
all hospitals enacted by section 211 of Public Law 106-554 effective
for discharges on or after April 1, 2001, and the positive effect of
the reclassification changes (2.6 percent increase).
The impact of lowering the DSH threshold is demonstrated in Column
8, although we would note that the estimated FY 2001 payments do
reflect 6 months of payments to hospitals affected by this change. The
impacts are seen in the rows displaying urban hospitals with fewer than
100 beds receiving DSH (4.0 percent increase), and all rural DSH
categories.
Among urban census divisions, payments increased between 1.3 and
3.3 percent between FY 2001 and FY 2002. The rural census division
experiencing the smallest increase in payments was the West North
Central region (2.6 percent). The largest increases by rural hospitals
is in Puerto Rico, where payments appear to increase by 9.9 percent,
and West South Central, where payments appear to increase by 4.8
percent. All 5 of the rural Puerto Rico hospitals experienced an
increase of greater than 10 percent in their wage index values
(comparison of FY 2001 and FY 2002). Rural New England, East South
Central, and South Atlantic regions also benefited with 3.7, 3.7, and
3.6 percent respectively.
Among special categories of rural hospitals, those hospitals
receiving payment under the hospital-specific methodology (SCHs, MDHs,
and SCH/RRCs) experience payment increases of 2.7 percent, 3.6 percent,
and 2.9 percent, respectively. This outcome is primarily related to the
fact that hospitals receiving payments under the hospital-specific
methodology are not eligible for outlier payments. Therefore,
[[Page 40092]]
these hospitals do not experience negative payment impacts from the
decline in outlier payments from FY 2001 to FY 2002 (from 6.2 percent
of total DRG plus outlier payments to 5.1 percent) as do hospitals paid
based on the national standardized amounts.
Among hospitals that were reclassified for FY 2002, hospitals
overall are estimated to receive a 3.3 percent increase in payments.
Urban hospitals reclassified for FY 2002 are anticipated to receive an
increase of 2.6 percent, while rural reclassified hospitals are
expected to benefit from reclassification with a 3.7 percent increase
in payments. Overall, among hospitals reclassified for purposes of the
standardized amount only, a payment increase of 3.8 percent is
expected, while those hospitals reclassified for purposes of the wage
index only show an expected 2.8 percent increase in payments. Those
hospitals located in rural counties but deemed to be urban under
section 1886(d)(8)(B) of the Act are expected to receive an increase in
payments of 4.2 percent.
Table II.--Impact Analysis of Changes For FY 2002 Operating Prospective Payment System
[Payments per case]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY
Num. of 2001 2002 All FY
hosp. payment payment 2002
per case\1\ per case\1\ changes
(1) (2) (3) (4)
----------------------------------------------------------------------------------------------------------------
By Geographic Location 4,795 6,994 7,141 2.1
All hospitals...............................................
Urban hospitals........................................... 2,704 7,559 7,703 1.9
Large urban areas (populations over 1 million)............ ...........
Other urban areas (populations of 1 million of fewer)... 1,143 6,853 6,989 2.0
Rural hospitals......................................... 2,091 4,808 4,972 3.4
Bed Size (Urban)............................................ 695 5,110 5,246 2.6
0-99 beds................................................. ........... ........... ........... ...........
100-199 beds.............................................. 948 6,313 6,444 2.1
200-299 beds.............................................. 529 7,218 7,364 2.0
300-499 beds.............................................. 383 8,139 8,283 1.8
500 or more beds.......................................... 149 9,875 10,035 1.6
Bed Size (Rural)............................................ 1,226 3,984 4,118 3.4
0-49 beds................................................. ........... ........... ........... ...........
50-99 beds................................................ 520 4,526 4,683 3.5
100-149 beds.............................................. 203 4,858 5,022 3.4
150-199 beds.............................................. 75 5,336 5,529 3.6
200 or more beds.......................................... 67 6,188 6,392 3.3
Urban by Region............................................. 138 8,014 8,254 3.0
New England...............................................
Middle Atlantic........................................... 416 8,600 8,713 1.3
South Atlantic............................................ 393 7,169 7,338 2.4
East North Central........................................ 459 7,215 7,335 1.7
East South Central........................................ 160 6,776 6,976 3.0
West North Central........................................ 187 7,342 7,470 1.7
West South Central........................................ 340 6,998 7,090 1.3
Mountain.................................................. 136 7,308 7,467 2.2
Pacific................................................... 429 8,939 9,109 1.9
Puerto Rico............................................... 46 3,207 3,312 3.3
Rural by Region............................................. 50 5,740 5,950 3.7
New England............................................... ........... ........... ........... ...........
Middle Atlantic........................................... 75 5,114 5,277 3.2
South Atlantic............................................ 269 4,950 51,128 3.6
East North Central........................................ 276 4,813 4,951 2.9
East South Central........................................ 263 4,423 4,587 3.7
West North Central........................................ 481 4,714 4,839 2.6
West South Central........................................ 333 4,249 4,452 4.8
Mountain.................................................. 195 5,168 5,321 3.0
Pacific................................................... 144 6,090 6,263 2.8
Puerto Rico............................................... 5 2,521 2,771 9.9
By Payment Classification: Urban hospitals.................. 2,746 7,538 7,682 1.9
Large urban hospitals (populations over 1 million).......... 1,632 8,026 8,175 1.9
Other urban hospitals (populations of 1 million or fewer)... 1,114 6,870 7,006 2.0
Rural hospitals............................................. 2,049 4,791 4,954 3.4
Teaching Status............................................. 3,668 5,638 5,775 2.4
Non-teaching.............................................. ........... ........... ........... ...........
Fewer than 100 Residents.................................. 890 7,327 7,473 2.0
100 or more Residents..................................... 237 11,280 11,473 1.7
Urban DSH................................................... 1,879 6,356 6,479 1.9
Non DSH................................................... ........... ........... ........... ...........
100 or more beds.......................................... 1,379 8,152 8,307 1.9
Less than 100 beds........................................ 316 4,973 5,173 4.0
Rural DSH................................................... 545 4,650 4,796 3.1
Sole Community (SCH)...................................... ........... ........... ........... ...........
Referral Center (RRC)..................................... 152 5,542 5,754 3.8
[[Page 40093]]
Other Rural................................................. 70 4,320 4,479 3.7
100 or more beds.......................................... ........... ........... ........... ...........
Less than 100 beds........................................ 454 3,937 4,115 4.5
Urban teaching and DSH: ........... ........... ........... ...........
Both teaching and DSH..................................... 758 9,081 9,250 1.9
Teaching and no DSH....................................... 298 7,577 7,715 1.8
No teaching and DSH....................................... 937 6,343 6,481 2.2
No teaching and no DSH.................................... 753 5,895 6,002 1.8
Rural Hospital Types ........... ........... ........... ...........
Non-special status........................................ 805 4,048 4,204 3.8
RRC....................................................... 165 5,433 5,636 3.7
SCH....................................................... 680 4,884 5,017 2.7
Medicare-dependent hospitals (MDH)........................ 329 3,852 3,991 3.6
SCH and RRC............................................... 70 5,902 6,073 2.9
Type of Ownership: Voluntary................................ 2,341 7,149 7,295 2.1
Proprietary............................................... 645 6,641 6,773 2.0
Government................................................ 962 6,259 6,437 2.8
Unknown................................................... 847 7,151 7,293 2.0
Medicare Utilization as a Percent of Inpatient Days:
0-25...................................................... 396 9,564 9,807 2.5
25-50..................................................... 1,886 8,045 8,195 1.9
50-65..................................................... 1,843 6,040 6,184 2.4
Over 65................................................... 592 5,422 5,543 2.2
Unknown................................................... 78 10,360 10,433 0.7
Hospitals Reclassified by the Medicare Geographic
Classification Review Board: FY 2002 Reclassifications:
All Reclassified Hospitals.................................. 628 6,234 6,438 3.3
Standardized Amount Only.................................. 74 5,210 5,409 3.8
Wage Index Only........................................... 391 6,103 6,270 2.8
Both...................................................... 58 6,876 6,919 0.6
All Nonreclassified Hospitals............................. 4,246 7,122 7,269 2.1
All Reclassified Urban Hospitals............................ 117 8,365 8,578 2.6
Standardized Amount Only.................................. 14 5,990 6,143 2.6
Wage Index Only........................................... 83 9,072 9,294 2.4
Both...................................................... 20 6,064 6,276 3.5
Urban Nonreclassified Hospitals........................... 2,549 7,539 7,678 1.8
All Reclassified Rural Hospitals............................ 511 5,383 5,584 3.7
Standardized Amount Only.................................. 16 5,183 5,302 2.3
Wage Index Only........................................... 472 5,387 5,589 3.7
Both...................................................... 23 5,381 5,597 4.0
Rural Nonreclassified Hospitals........................... 1,577 4,271 4,399 3.0
Other Reclassified Hospitals (Section 1886(D)(8)(B))........ 41 4,838 5,043 4.2
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.
Table II presents the projected impact of the final changes for FY
2002 for urban and rural hospitals and for the different categories of
hospitals shown in Table I. It compares the estimated payments per case
for FY 2001 with the average estimated per case payments for FY 2002,
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.
IX. Impact for Critical Access Hospitals (CAHs)
There are approximately 365 facilities that qualify as CAHs. These
CAHs are paid based on reasonable costs for their services to
inpatients and outpatients. We examined several parts of the final
rule, as discussed in detail in section VI.B. of the preamble, for
their potential impact on CAHs.
A. Exclusion of CAHs From Payment Window Requirements
In this final rule, we are clarifying the policy that CAHs are not
subject to the payment window provisions of section 1886(a)(3) of the
Act. Existing regulations do not require application of these
provisions to CAHs, and we are not aware of specific situations in
which they are now being applied. Consequently, we do not expect any
increase or decrease in Medicare spending based on this clarification.
B. Availability of CRNA Pass-Through for CAHs
Under existing Sec. 412.113(c), CRNA pass-through payment is
available only to hospitals that either qualified for the pass-through
of costs of anesthesia services furnished in calendar year 1989, or met
certain conditions, including having employed or contracted with a
qualified nonphysician anesthetist as of January
[[Page 40094]]
1, 1988, to perform anesthesia services. In this final rule, we are
specifying that certain CAHs that meet the pass-through criteria would
qualify for pass-through payments. Under the existing criterion, we
believe the only facilities that could qualify for the pass-through as
CAHs are those that would have qualified for the pass-through if they
had elected to continue participating in Medicare as hospitals rather
than converting to CAH status. We do not expect any increase or
decrease in Medicare spending based on the final change in the
regulations.
C. Payment for Emergency Room On-Call Physicians
In accordance with the amendments made by section 204 of Public Law
106-544, in this final rule, we are specifying that we will recognize
as allowable costs, amounts for reasonable compensation and related
costs for emergency room physicians who are on call but who are not
present on the premises of a CAH. We expect that at least some CAHs
will elect to compensate emergency room physicians for being on call
and that, as a result, Medicare spending for CAH services will
increase. However, we do not have information to develop a reliable
estimate of how many CAHs will make this election, or how much
physician compensation costs they will incur for on call time.
D. Treatment of Ambulance Services Furnished by Certain CAHs
In accordance with the provisions of section 205 of Public Law 106-
554, we are amending the existing CAH regulations to provide for
payment to CAHs for the reasonable costs of ambulance services
furnished by a CAH or an entity owned or operated by the CAH if certain
statutory requirements are met. We expect that at least some CAHs or
entities owned or operated by CAHs will be able to qualify for payment
for their ambulance services. To the extent that CAHs or CAH owned or
operated entities furnish these services under the conditions specified
in the law, ambulance services will be paid for at higher rates than
would otherwise apply. As a result, Medicare spending for ambulance
services will increase. However, we do not have sufficient information
or data to develop a reliable estimate of how many CAHs or entities
will qualify or the dollar amount of ambulance service costs they will
incur.
E. Qualified Practitioners for Preanesthesia and Postanesthesia
Evaluations in CAHs
As discussed in section VI.B. of this final rule, in an effort to
eliminate or minimize potential issues relating to beneficiary access
to medical services in rural areas, we are allowing CRNAs who
administer the anesthesia to conduct the preanesthesia and
postanesthesia evaluations in a CAH. As with any licensed independent
health care provider, the final change will not permit CRNAs to
practice beyond his or her licensed scope of practice.
We believe that this policy will increase flexibility of providers
in furnishing medical services in rural areas. However, we do not have
information or data to develop a reliable estimate of how many CRNAs
would be used to conduct preanesthesia and postanesthesia evaluations
in CAHs or what the associated costs would be.
X. Impact of Changes in the Capital Prospective Payment System
A. General Considerations
We now have cost report data for the 8th year of the capital
prospective payment system (cost reports beginning in FY 1999)
available through the March 2001 update of the HCRIS. We also have
updated information on the projected aggregate amount of obligated
capital approved by the fiscal intermediaries. However, our impact
analysis of payment changes for capital-related costs is still limited
by the lack of hospital-specific data on several items. These are the
hospital's projected new capital costs for each year, its projected old
capital costs for each year, and the actual amounts of obligated
capital that will be put in use for patient care and recognized as
Medicare old capital costs in each year. The lack of this information
affects our impact analysis in the following ways:
Major investment in hospital capital assets (for example,
in building and major fixed equipment) occurs at irregular intervals.
As a result, there can be significant variation in the growth rates of
Medicare capital-related costs per case among hospitals. We do not have
the necessary hospital-specific budget data to project the hospital
capital growth rate for individual hospitals.
Our policy of recognizing certain obligated capital as old
capital makes it difficult to project future capital-related costs for
individual hospitals. Under Sec. 412.302(c), a hospital is required to
notify its intermediary that it has obligated capital by the later of
October 1, 1992, or 90 days after the beginning of the hospital's first
cost reporting period under the capital prospective payment system. The
intermediary must then notify the hospital of its determination whether
the criteria for recognition of obligated capital have been met by the
later of the end of the hospital's first cost reporting period subject
to the capital prospective payment system or 9 months after the receipt
of the hospital's notification. The amount that is recognized as old
capital is limited to the lesser of the actual allowable costs when the
asset is put in use for patient care or the estimated costs of the
capital expenditure at the time it was obligated. We have substantial
information regarding fiscal intermediary determinations of projected
aggregate obligated capital amounts. However, we still do not know when
these projects will actually be put into use for patient care, the
actual amount that will be recognized as obligated capital when the
project is put into use, or the Medicare share of the recognized costs.
Therefore, we do not know actual obligated capital commitments for
purposes of the FY 2002 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 2002 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 2002. In addition, we have
integrated sufficient hospital-specific information into our actuarial
model to project the impact of the FY 2002 capital payment policies by
the standard prospective payment system hospital groupings. While we
now have actual information on the effects of the transition payment
methodology and interim payments under the capital prospective payment
system and cost report data for most hospitals, we still need to
randomly generate numbers for the change in old capital costs, new
capital costs for each year, and obligated amounts that will be put in
use for patient care services and recognized as old capital each year.
We continue to be unable to predict accurately FY 2002 capital costs
for individual hospitals, but with the most recent data on hospitals'
experience under the capital prospective payment system, there is
adequate information to estimate the aggregate impact on most hospital
groupings.
[[Page 40095]]
B. Projected Impact Based on the FY 2002 Actuarial Model
1. Assumptions
In this impact analysis, we model dynamically the impact of the
capital prospective payment system from FY 2001 to FY 2002 using a
capital cost model. The FY 2002 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 1999 as reported on the
March 2001 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, 2001 in the
provider-specific file. We used these data to determine the FY 2002
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 1999, 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 1999. All Federal rate payment parameters are assigned to the
applicable hospital. We will continue to pay regular exceptions during
cost reporting periods beginning before October 1, 2001 but ending in
FY 2002. However, in FY 2003 and later, payments will no longer be made
under the regular exceptions provision; hence, we will no longer
require the actuarial model described in Appendix B of this final rule.
For purposes of this impact analysis, the FY 2002 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
------------------------------------------------------------------------
2000....................................................... 1.39
2001....................................................... 1.37
2002....................................................... 2.58
------------------------------------------------------------------------
We estimate that the Medicare case-mix index will decrease
by 0.9 percent in FY 2001 and will increase by 1.0 percent in FY 2002.
The Federal capital rate and the hospital-specific rate
were updated beginning 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 2002
update is 1.3 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 2001 to FY 2002. 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. We are no longer displaying a column for
the hospital-specific payments in Table III since, beginning with FY
2001, the transition blend percentage for fully prospective hospitals
is 100 percent of the Federal rate and zero percent of the hospital-
specific rate, and all hospitals (except ``new'' hospitals under
Sec. 412.324(b)) are paid based on 100 percent of the Federal rate for
FY 2002. Based on our actuarial model, the breakdown of hospitals is as
follows:
Capital Transition Payment Methodology for FY 2002
----------------------------------------------------------------------------------------------------------------
Percent of Percent of
Type of hospital Percent of Percent of capital capital
hospitals discharges costs payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital........................................... 66 62 57 61
High Cost Hospital.......................................... 34 38 43 39
----------------------------------------------------------------------------------------------------------------
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(c) 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 2001 to FY 2002
using the above described actuarial model. With the Federal rate, we
estimate aggregate Medicare capital payments will increase by 4.27
percent in FY 2002. This increase is noticeably somewhat lower than
last year's (5.48 percent) due in part to the fact that because the
transition period ends after FY 2001, there is no longer an increase in
the Federal blend percentage, which increased from 90 to 100 percent
from FY 2000 to FY 2001, for fully prospective hospitals.
Table III.--Impact of Changes for FY 2002 on Payments Per Discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Average Hold Percent
Number of Discharges federal federal harmless Exceptions Total change over
hospitals payment percent payment payment payment FY 2001
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2001 Payments per Discharge:
Low Cost Hospitals............................ 3,127 6,769,127 $620.00 99.66 $2.99 $5.30 $628.28 ...........
Fully Prospective........................... 2,942 6,276,252 621.64 100.00 ........... 4.89 626.53 ...........
100% Federal Rate........................... 169 456,256 617.75 100.00 ........... 6.16 623.91 ...........
[[Page 40096]]
Hold Harmless............................... 16 36,620 366.68 48.18 552.28 64.01 982.96 ...........
High Cost Hospitals........................... 1,580 4,165,866 632.93 98.07 16.77 9.18 658.87 ...........
100% Federal Rate........................... 1,408 3,837,475 644.77 100.00 ........... 7.11 651.88 ...........
Hold Harmless............................... 172 328,391 494.55 75.83 212.71 33.31 740.57 ...........
Total Hospitals............................... 4,707 10,934,994 624.92 99.04 8.24 6.77 639.94 ...........
FY 2002 Payments per Discharge:
Low Cost Hospitals............................ 3,127 6,877,112 643.74 100.00 ........... 2.85 646.59 2.91
Fully Prospective........................... 2,942 6,376,366 643.23 100.00 ........... 2.92 646.14 3.13
100% Federal Rate........................... 185 500,747 650.23 100.00 ........... 2.07 652.29 4.55
High Cost Hospitals........................... 1,580 4,232,640 667.73 100.00 ........... 5.55 673.28 2.19
100% Federal Rate........................... 1,580 4,232,640 667.73 100.00 ........... 5.55 673.28 3.28
Total Hospitals............................... 4,707 11,109,753 652.88 100.00 ........... 3.88 656.76 2.63
--------------------------------------------------------------------------------------------------------------------------------------------------------
We project that low capital cost hospitals paid under the fully
prospective payment methodology will experience an average increase in
payments per case of 2.91 percent, and high capital cost hospitals will
experience an average increase of 2.19 percent. These results are due
to the fact that there is no longer an increase in the Federal blend
percentage with the conclusion of the capital transition period in FY
2001 for fully prospective hospitals. Beginning FY 2002, all hospitals
(except ``new'' hospitals under Sec. 412.324(b)) are paid based on 100
percent of the Federal rate for FY 2002.
For hospitals paid under the fully prospective payment methodology,
the Federal rate payment percentage remains at 100 percent from FY 2001
(the last year of the transition period) and since they no longer
receive payments based on the hospital-specific rate. The Federal rate
payment percentage in FY 2001 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 in FY 2001 will increase from 75.83 percent to 100
percent since the transition period will have ended. All hold-harmless
hospitals (except ``new'' hospitals under Sec. 413.324(b)) will be paid
based on 100 percent of the Federal rate in FY 2002. We estimate that
high cost hospitals (paid based on 100 percent of the Federal rate)
will receive a decrease in exceptions payments from $7.11 per discharge
in FY 2001 to $5.55 per discharge in FY 2002. This is primarily due to
the expiration of the regular exceptions provision in FY 2002.
We are no longer presenting the average hospital-specific rate
payment per discharge in Table III because, beginning with FY 2001, the
transition blend percentage for fully prospective hospitals is 100
percent of the Federal rate and zero percent of the hospital-specific
rate, and all hospitals (except ``new'' hospitals under
Sec. 412.324(b)) will be paid based on 100 percent of the Federal rate
for FY 2002.
As stated previously, we will continue to pay regular exceptions
for cost reporting periods beginning before October 1, 2001, but ending
in FY 2002. However, in FY 2003 and later, regular exception payments
will no longer be made under the regular exceptions provision but
eligible hospitals could receive special exception payments under
Sec. 412.348(g).
We estimate that regular exceptions payments will decrease from
1.06 percent of total capital payments in FY 2001 to 0.59 percent of
payments in FY 2002. These results are primarily due to the expiration
of the regular exceptions after FY 2001 and the limited nature of the
special exceptions policy in FY 2002. The projected distribution of the
exception payments is shown in the chart below:
Estimated FY 2002 Exceptions Payments
------------------------------------------------------------------------
Percent of
Type of hospital Number of exceptions
hospitals payments
------------------------------------------------------------------------
Low Capital Cost.............................. 104 46
High Capital Cost............................. 112 54
-------------------------
Total..................................... 216 100
------------------------------------------------------------------------
In the past we presented a cross-sectional summary of hospital
groupings by the capital prospective payment transition period
methodology generated by our actuarial model (Appendix B). We are no
longer including such a comparison since all hospitals (except ``new''
hospitals under Sec. 412.324(b)) will be paid based on 100 percent of
the Federal rate in FY 2002 with the conclusion of the 10-year capital
transition period.
C. Cross-Sectional Analysis of Changes in Aggregate Payments
We used our FY 2002 actuarial model to estimate the potential
impact of our changes for FY 2002 on total capital payments per case,
using a universe of 4,707 hospitals. The individual hospital payment
parameters are taken from the best available data, including: the April
1, 2001 update to the provider-specific file, cost report data, and
audit information supplied by intermediaries. In Table IV, we present
the results of the cross-sectional analysis using the results of our
actuarial model and the aggregate impact of the FY 2002 payment
policies. As we explain in Appendix B of this final rule, we were not
able to use 88 of the 4,795 hospitals in our database due to
insufficient (missing or unusable) data. Consequently, the payment
methodology distribution is based on 4,707 hospitals. These data should
be fully representative of the payment methodologies that will be
applicable to hospitals. Columns 3 and 4 show estimates of payments per
case under our model for FY 2001 and FY 2002, respectively. Column 5
shows the total percentage change in payments from FY 2001 to FY 2002.
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 2.28
percent increase in the Federal rate, a 1.0 percent increase in case
mix, changes in the adjustments to the Federal rate (for example, the
effect of the new hospital wage index on the geographic adjustment
factor), and reclassifications by the MGCRB. Column 5 includes the
effects of the Federal rate changes represented in Column 6. Column 5
also reflects the effects of all other changes, including the change
for all hold-harmless hospitals being paid based on 100 percent of the
Federal rate, and changes in exception payments. The comparisons are
provided by: (1)
[[Page 40097]]
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 2002. The results
show that the effect of the Federal rate change alone is to increase
payments by 3.4 percent. In addition to the increase attributable to
the Federal rate change, a 0.8 percent decrease is attributable to the
effects of all other changes.
Our comparison by geographic location shows an overall increase in
payments to hospitals in all areas. This comparison also shows that
urban and rural hospitals will experience slightly different rates of
increase in capital payments per case (2.7 percent and 2.0 percent,
respectively). This difference is due to the lower rate of decrease for
urban hospitals relative to rural hospitals (0.7 percent and 1.4
percent, respectively) from the effect of all other changes. Urban
hospitals will gain the same as rural hospitals (3.4 percent) from the
effects of Federal rate changes alone.
Most regions are estimated to receive increases in total capital
payments per case, partly due to the fact that payments to all
hospitals (except ``new'' hospitals under Sec. 412.324(b)) will be
based on 100 percent of the Federal rate in FY 2002. Changes by region
vary from a minimum increase of 0.7 percent (Mountain rural region) to
a maximum increase of 3.5 percent (East North Central region).
By type of ownership, voluntary hospitals are projected to have the
largest rate of increase of total payment changes (2.8 percent, a 3.4
percent increase due to the Federal rate changes, and a 0.6 percent
decrease from the effects of all other changes). Similarly, payments to
government hospitals will increase 2.2 percent (a 3.4 percent increase
due to Federal rate changes, and a 1.2 percent decrease from the
effects of all other changes), while payments to proprietary hospitals
will increase 0.9 percent (a 3.3 percent increase due to Federal rate
changes, and a 2.4 percent decrease from the effects of all other
changes). This 2.4 percent decrease from all other changes is primarily
due to the estimated decrease in exceptions payments and the change for
all hold-harmless hospitals being paid based on 100 percent of the
Federal rate.
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 also 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
2002 compared to the effects of reclassification for FY 2001, we show
the average payment percentage increase for hospitals reclassified in
each fiscal year and in total. For FY 2002 reclassifications, we
indicate those hospitals reclassified for standardized amount purposes
only, for wage index purposes only, and for both purposes. The
reclassified groups are compared to all other nonreclassified
hospitals. These categories are further identified by urban and rural
designation.
Hospitals reclassified for FY 2002 as a whole are projected to
experience a 2.5 percent increase in payments (a 3.4 percent increase
attributable to Federal rate changes and a 0.9 percent decrease
attributable to the effects of all other changes). Payments to
nonreclassified hospitals will increase slightly more (2.6 percent)
than reclassified hospitals (2.5 percent) overall. Payments to
nonreclassified hospitals will increase the same as reclassified
hospitals from the Federal rate changes (3.4 percent), and they will
lose slightly less from the effects of all other changes (0.8 percent
compared to 0.9 percent, respectively).
Table IV.--Comparison of Total Payments Per Case
[FY 2001 Payments compared to FY 2002 payments]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY Portion
Number of 2001 2002 attributable
hospitals payments/ payments/ All charges to federal
case case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................... 4,707 640 657 2.6 3.4
Large urban areas (populations over 1 1,518 742 763 2.9 3.4
million)...................................
Other urban areas (populations of 1 million 1,110 629 645 2.5 3.4
fewer).....................................
Rural areas................................. 2,079 433 442 2.0 3.4
Urban hospitals............................. 2,628 693 712 2.7 3.4
0-99 beds................................. 638 504 501 -0.6 3.2
100-199 beds.............................. 932 591 604 2.3 3.3
200-299 beds.............................. 527 662 681 2.9 3.4
300-499 beds.............................. 382 734 757 3.2 3.4
500 or more beds.......................... 149 890 917 3.0 3.4
Rural hospitals............................. 2,079 433 442 2.0 3.4
0-49 beds................................. 1,218 364 371 1.7 3.3
50-99 beds................................ 516 406 414 1.9 3.3
100-149 beds.............................. 203 443 450 1.8 3.4
150-199 beds.............................. 75 482 494 2.4 3.3
200 or more beds.......................... 67 541 553 2.2 3.4
By Region:
Urban by Region............................. 2,628 693 712 2.7 3.4
New England............................... 137 733 757 3.4 3.5
Middle Atlantic........................... 406 776 797 2.6 3.3
South Atlantic............................ 391 665 682 2.5 3.4
East North Central........................ 445 666 690 3.5 3.4
East South Central........................ 156 628 643 2.4 3.4
West North Central........................ 179 687 708 3.0 3.4
[[Page 40098]]
West South Central........................ 319 659 668 1.4 3.3
Mountain.................................. 126 681 690 1.3 3.4
Pacific................................... 423 783 808 3.3 3.4
Puerto Rico............................... 46 290 299 3.1 3.1
Rural by Region............................. 2,079 433 442 2.0 3.4
New England............................... 50 519 530 2.1 3.4
Middle Atlantic........................... 74 453 467 3.1 3.4
South Atlantic............................ 269 449 455 1.2 3.3
East North Central........................ 276 441 452 2.4 3.4
East South Central........................ 260 403 412 2.2 3.4
West North Central........................ 479 421 430 2.3 3.4
West South Central........................ 327 388 393 1.4 3.3
Mountain.................................. 195 458 461 0.7 3.2
Pacific................................... 144 513 528 3.0 3.4
By Payment Classification:
All hospitals............................... 4,707 640 657 2.6 3.4
Large urban areas (populations over 1 1,589 735 756 2.8 3.4
million)...................................
Other urban areas (populations of 1 million 1,081 631 647 2.5 3.4
or fewer)..................................
Rural areas................................. 2,037 431 440 2.1 3.4
Teaching Status:
Non-teaching.............................. 3,582 526 536 2.0 3.4
Fewer than 100 Residents.................. 888 668 689 3.1 3.4
100 or more Residents..................... 237 996 1,027 3.1 3.4
Urban DSH:
100 or more beds.......................... 1,374 729 750 2.8 3.4
Less than 100 beds........................ 309 483 486 0.5 3.2
Rural DSH:
Sole Community (SCH/EACH)................... 545 395 395 0.1 3.2
Referral Center (RRC/EACH)................ 152 495 505 1.9 3.4
Other Rural:
100 or more beds........................ 70 407 418 2.6 3.3
Less than 100 beds...................... 449 366 378 3.0 3.4
Urban teaching and no DSH:
Both teaching and DSH..................... 757 805 829 3.0 3.4
Teaching and no DSH....................... 297 712 737 3.4 3.4
No teaching and DSH....................... 926 583 596 2.2 3.3
No teaching and no DSH.................... 690 577 587 1.7 3.4
Rural Hospital Types:
Non special status hospitals................ 794 381 392 3.1 3.4
RRC/EACH.................................... 165 498 513 3.0 3.4
SCH/EACH.................................. 680 417 418 0.2 3.2
Medicare-dependent hospitals (MDH)........ 328 353 363 2.8 3.4
SCH, RRC and EACH......................... 70 500 503 0.6 3.3
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY01 and
FY02:
Reclassified During Both FY01 and FY02.. 475 560 573 2.4 3.4
Reclassified During FY02 Only............. 152 558 573 2.7 3.4
Reclassified During FY01 Only............. 51 489 504 3.0 3.4
FY02 Reclassifications:
All Reclassified Hospitals................ 627 559 573 2.5 3.4
All Nonclassified Hospitals................. 4,159 652 670 2.6 3.4
All Urban Reclassified Hospitals.......... 117 742 765 3.1 3.4
Urban nonreclassified Hospitals........... 2,473 692 711 2.7 3.4
All Reclassified Rural Hospitals.......... 510 486 496 2.1 3.4
Rural Nonreclassified Hospitals........... 1,566 384 391 1.8 3.3
Other Reclassified Hospitals (Section 41 439 452 3.0 3.4
1886(D)(8)(B)).............................
Type of Ownership:
Voluntary................................... 2,327 654 672 2.8 3.4
Proprietary................................. 627 632 637 0.9 3.3
Government.................................. 954 558 570 2.2 3.4
Medicare Utilization as a Percent of Inpatient
Days:
0-25...................................... 390 831 854 2.7 3.4
25-50..................................... 1,873 729 750 3.0 3.4
50-65..................................... 1,832 561 576 2.6 3.4
Over 65................................... 585 514 516 0.3 3.3
----------------------------------------------------------------------------------------------------------------
[[Page 40099]]
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 will continue to pay regular exceptions for cost reporting
periods beginning before October 1, 2001 but ending in FY 2002. In
FY 2003 and later, no payments will be made under the regular
exceptions policy; hence, we will not compute a budget neutrality
factor for regular exceptions in FY 2003 and later. As described in
section V.D. of the preamble of this final rule, the budget
neutrality adjustment for special exceptions will be based on
historical costs. Consequently, there will be no need to estimate
capital costs with the capital acquisition model. We will not
publish this appendix after this final rule for the FY 2002 capital
rates.
We used the capital acquisition model from the start of
prospective payments for capital costs through FY 1997. We now have
8 years of cost reports under the capital prospective payment
system. For FY 1998, we developed a new capital cost model to
replace the capital acquisition model. This revised model makes use
of the data from these cost reports.
The following cost reports are used in the capital cost model
for this proposed rule: the March 31, 2001 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), PPS-XIV (cost reporting periods beginning in
FY 1997), PPS-XV (cost reporting periods beginning in FY 1998), and
PPS-XVI (cost reporting periods beginning in FY 1999). In addition,
to model payments, we use the April 1, 2001 update of the provider-
specific file, and the March 1995 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 2001 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
------------------------------------------------------------------------
No Match............................................. 1
Provider-Specific File Only.......................... 188
Provider-Specific and Audit File..................... 4,606
------------------
Total............................................ 4,795
------------------------------------------------------------------------
One hundred sixteen of the 4,795 hospitals had unusable or
missing data, or had no cost reports available. For 50 of the 116
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 50 hospitals in the analysis. We were
able to estimate hospital-specific amounts from the cost reports as
shown in the following table.
------------------------------------------------------------------------
Number of
Cost report hospitals
------------------------------------------------------------------------
PPS-9...................................................... 1
PPS-12..................................................... 1
PPS-13..................................................... 1
PPS-14..................................................... 1
PPS-15..................................................... 2
PPS-16..................................................... 13
------------
Total.................................................. 19
------------------------------------------------------------------------
Hence, we were able to use 69 (50 plus 19) of the 116 hospitals.
The remaining 47 of the 116 hospitals could not be used in the
analysis because we were not able to estimate their hospital-
specific amount. An additional 41 hospitals could not be used in the
analysis because we could not determine their capital costs, either
because we had no cost reports for them or because there was
insufficient cost report data. Accordingly, we used 4,707 hospitals
for the analysis. Eighty-eight (47 plus 41) hospitals could not be
used in the analysis because of insufficient (missing or unusable)
information. These hospitals account for about 0.3 percent of
admissions. Therefore, any effects from the elimination of their
cost report data should be minimal.
We analyzed changes in capital-related costs (depreciation,
interest, rent, leases, insurance, and taxes) reported in the cost
reports. We found a wide variance among hospitals in the growth of
these costs. For hospitals with more than 100 beds, the distribution
and mean of these cost increases were different for large changes in
bed-size (greater than 20 percent). We also analyzed
changes in the growth in old capital and new capital for cost
reports that provided this information. For old capital, we limited
the analysis to decreases in old capital. We did this since the
opportunity for most hospitals to treat ``obligated'' capital put
into service as old capital has expired. Old capital costs should
decrease as assets become fully depreciated and as interest costs
decrease as the loan is amortized.
The new capital cost model separates the hospitals into three
mutually exclusive groups. Hold-harmless hospitals with data on old
capital were placed in the first group. Of the remaining hospitals,
those hospitals with fewer than 100 beds comprise the second group.
The third group consists of all hospitals that did not fit into
either of the first two groups. Each of these groups displayed
unique patterns of growth in capital costs. We found that the gamma
distribution is useful in explaining and describing the patterns of
increase in capital costs. A gamma distribution is a statistical
distribution that can be used to describe patterns of growth rates,
with the greatest proportion of rates being at the low end. We use
the gamma distribution to estimate individual hospital rates of
increase as follows:
(1) For hold-harmless hospitals, old capital cost changes were
fitted to a truncated gamma distribution, that is, a gamma
distribution covering only the distribution of cost decreases. New
capital costs changes were fitted to the entire gamma distribution,
allowing for both decreases and increases.
(2) For hospitals with fewer than 100 beds (small), total
capital cost changes were fitted to the gamma distribution, allowing
for both decreases and increases.
(3) Other (large) hospitals were further separated into three
groups:
Bed-size decreases over 20 percent (decrease).
Bed-size increases over 20 percent (increase).
Other (no change).
Capital cost changes for large hospitals were fitted to gamma
distributions for each bed-size change group, allowing for both
decreases and increases in capital costs. We analyzed the
probability distribution of increases and decreases in bed size for
large hospitals. We found the probability somewhat dependent on the
prior year change in bed size and factored this dependence into the
analysis. Probabilities of bed-size change were determined. Separate
sets of probability factors were calculated to reflect the
dependence on prior year change in bed size (increase, decrease, and
no change).
The gamma distributions were fitted to changes in aggregate
capital costs for the entire hospital. We checked the relationship
between aggregate costs and Medicare per discharge costs. For large
hospitals, there was a small variance, but the variance was larger
for small hospitals. Since costs are used only for the hold-harmless
methodology and to determine exceptions, we decided to use the gamma
distributions fitted to aggregate cost increases for estimating
distributions of cost per discharge increases.
Capital costs per discharge calculated from the cost reports
were increased by random
[[Page 40100]]
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
2000 (the MedPAR data year) and later, we use the number of
discharges from the MedPAR data. Some hospitals had considerably
more discharges in FY 2000 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 2000 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 2000 MedPAR file using the FY 2002 DRG relative weights
included in section VI. of the Addendum to this final rule. The
case-mix index is increased each year after FY 2000 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 0.9 percent in FY 2001. We project that case-mix will
increase 1.0 percent in FY 2002. (Since we are using FY 2000 cases
for our analysis, the FY 2000 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 2001, the budget neutrality adjustment factors
were 0.99933 for the national rate and 1.00508 for the Puerto Rico
rate. In determining these factors, we used the factors from the
first half of FY 2001 (October 2000 through March 2001) published in
the August 1, 2000 final rule since section 547 of Public Law 106-
554 specifies that the special increases and adjustments in effect
between April and October 2001 do not apply for discharges occurring
after FY 2001 and should not be included in determining the payment
rates in subsequent years.
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 FY 1998.
To determine the factors for FY 2002, we first determined the
portions of the Federal national and Puerto Rico rates that would be
paid for each hospital in FY 2002 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 2001 DRG relative weights and the FY
2001 geographic adjustment factor to estimated aggregate Federal
rate payments based on the FY 2001 relative weights and the FY 2002
geographic adjustment factor. In making the comparison, we held the
FY 2002 Federal rate portion constant and set the other budget
neutrality adjustment factor and the regular and special exceptions
reduction factors to 1.00. To achieve budget neutrality for the
changes in the national geographic adjustment factor, we applied an
incremental budget neutrality adjustment of 0.99666 for FY 2002 to
the previous cumulative FY 2001 adjustment of 0.99933, yielding a
cumulative adjustment of 0.99599 through FY 2002. For the Puerto
Rico geographic adjustment factor, we applied an incremental budget
neutrality adjustment of 0.98991 for FY 2002 to the previous
cumulative FY 2001 adjustment of 1.00508, yielding a cumulative
adjustment of 0.99494 through FY 2002. We then compared estimated
aggregate Federal rate payments based on the FY 2001 DRG relative
weights and the FY 2002 geographic adjustment factors to estimated
aggregate Federal rate payments based on the FY 2002 DRG relative
weights and the FY 2002 geographic adjustment factors. The
incremental adjustment for DRG classifications and changes in
relative weights is 0.99668 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 2002 are 0.99268 nationally and 0.99164 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 Geographic
DRG Cumulative DRG Cumulative
adjustment reclassifications Combined adjustment reclassifications Combined
factor and recalibration factor and recalibration
--------------------------------------------------------------------------------------------------------------------------------------------------------
1992...................................... .......... ................. .......... 1.00000 .......... ................. .......... ..........
1993...................................... .......... ................. 0.99800 0.99800 .......... ................. .......... ..........
[[Page 40101]]
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
2001\1\................................... 0.99846 1.00019 0.99865 0.99933 1.00365 1.00009 1.00374 1.00508
2001\2\................................... \3\ 0.9977 \3\ 1.00009 \3\ 0.9978 0.99922 \3\ 1.0036 \3\ 1.00009 \3\ 1.0037 1.00508
1 0 5 4
2002...................................... \4\ 0.9966 \4\ 0.99668 \4\ 0.9933 0.99268 \4\ 0.9899 \4\ 0.99668 \4\ 0.9966 0.99164
6 5 1 2
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Factors effective for the first half of FY 2001 (October 2000 through March 2001).
\2\ Factors effective for the second half of FY 2001 (April 2001 through September 2001).
\3\ Incremental factors are applied to FY 2000 cumulative factors.
\4\ Incremental factors are applied to the cumulative factors for the first half of FY 2001.
The methodology used to determine the recalibration and
geographic (DRG/GAF) budget neutrality adjustment factor is similar
to that used in establishing budget neutrality adjustments under the
prospective payment system for operating costs. One difference is
that, under the operating prospective payment system, the budget
neutrality adjustments for the effect of geographic
reclassifications are determined separately from the effects of
other changes in the hospital wage index and the DRG relative
weights. Under the capital prospective payment system, there is a
single DRG/GAF budget neutrality adjustment factor (the national
rate and the Puerto Rico rate are determined separately) for changes
in the geographic adjustment factor (including geographic
reclassification) and the DRG relative weights. In addition, there
is no adjustment for the effects that geographic reclassification
has on the other payment parameters, such as the payments for
serving low-income patients or the large urban add-on payments.
In addition to computing the DRG/GAF budget neutrality
adjustment factor, we used the model to simulate total payments
under the prospective payment system.
Additional payments under the exceptions process are accounted
for through a reduction in the Federal and hospital-specific rates.
For FY 2002 additional payments for the ``regular'' exceptions are
made only for cost reporting periods that begin before October 1,
2001. The adjustment for ``special'' exceptions payments (see
Sec. 412.348(g)) is described in section V.D. of the preamble of
this final rule. 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. In
modeling exceptions for FY 2002, we calculated exceptions only for
qualifying cost reporting periods. 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.
Since we will no longer use the model after this final rule for the
FY 2002 rates, we will discontinue publishing this table after this
final rule for the FY 2002 rates. The table below provides the
actual factors for FYs 1992 through 2002, and the estimated factors
that would be applicable through FY 2006. We caution that these are
estimates for FYs 2003 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
0.99268 (0.99164 for Puerto Rico) for FY 2002 and later because we
do not have sufficient information to estimate the change that will
occur in the factor for years after FY 2002.
The projections are as follows:
----------------------------------------------------------------------------------------------------------------
Federal
Exceptions Budget DRG/GAF Outlier Federal rate
Fiscal year Update reduction neutrality adjustment adjustment rate (after
factor factor factor factor\1\ factor adjustment outlier)
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\5\..................... 0.90 .9785 N/A .9979 .9409 .......... 382.03
2002........................ 1.30 \6\.9929 N/A 0.9933 .9424 .......... 390.74
2003........................ 0.70 .9975 N/A \7\1.0000 \7\.9424 \4\1.0255 405.39
2004........................ 0.70 .9975 N/A 1.0000 .9424 .......... 408.23
2005........................ 0.90 .9975 N/A 1.0000 .9424 .......... 411.90
2006........................ 0.90 .9975 N/A 1.0000 .9424 .......... 415.61
----------------------------------------------------------------------------------------------------------------
\1\ The incremental change over the previous year.
\2\ OBRA 1993 adjustment.
\3\ Adjustment for change in the transfer policy.
\4\ Balanced Budget Act of 1997 adjustment.
\5\ Rates are for the first half of FY 2001 (October 1, 2000 through March 31, 2001).
\6\ Product of general exceptions factor (0.9941) and special exceptions factor (0.9988)
[[Page 40102]]
\7\ Future adjustments are, for purposes of this projection, assumed to remain at the same level.
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 2002 by hospitals
subject to the prospective payment system and by hospitals or units
excluded from the prospective payment system. Section
1886(b)(3)(B)(i)(XVII) of the Act, as amended by section 301 of
Public Law 106-554, sets the FY 2002 percentage increase in the
operating cost standardized amounts equal to the rate of increase in
the hospital market basket minus 0.55 percentage points for
prospective payment hospitals in all areas. Section
1886(b)(3)(B)(iv) of the Act sets the FY 2002 percentage increase in
the hospital-specific rates applicable to SCHs and MDHs 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
0.55 percentage points. Under section 1886(b)(3)(B)(ii) of the Act,
the FY 2002 percentage increase in the rate-of-increase limits for
hospitals and units excluded from the prospective payment system
ranges from the percentage increase in the excluded hospital market
basket less a percentage between 0 and 2.5 percentage points,
depending on the hospital's or unit's costs in relation to its limit
for the most recent cost reporting period for which information is
available, or 0 percentage point if costs do not exceed two-thirds
of the limit.
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 and units excluded from
the prospective payment system as provided in section 1886(b)(3)(B)
of the Act. Based on the second quarter 2001 forecast of the FY 2002
market basket increase of 3.3 percent for hospitals subject to the
prospective payment system, the update to the standardized amounts
is 2.75 percent (that is, the market basket rate of increase minus
0.55 percentage points) for hospitals in both large urban and other
areas. The update to the hospital-specific rate applicable to SCHs
and MDHs is also 2.75 percent. The update for hospitals and units
excluded from the prospective payment system can range from the
percentage increase in the excluded hospital market basket
(currently estimated at 3.3 percent) minus a percentage between 0
and 2.5 percentage points, or 0 percentage point, resulting in an
increase in the rate-of-increase limit between 0.8 and 3.3 percent,
or 0 percent.
Section 1886(e)(4) of the Act requires that the Secretary,
taking into consideration the recommendations of the Medicare
Payment Advisory Commission (MedPAC), recommend update factors for
each fiscal year that take into account the amounts necessary for
the efficient and effective delivery of medically appropriate and
necessary care of high quality. In its March 1, 2001 report, MedPAC
stated that the legislated update of market basket minus 0.55
percentage points would provide a reasonable level of payments to
hospitals. MedPAC did not make a separate recommendation for the
hospital-specific rate applicable to SCHs and MDHs.
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 2002 update factors recommended by
the Secretary as Appendix D of the May 4, 2001 proposed rule (66 FR
22888). In that appendix, we discussed the recommendations of
appropriate update factors, the analysis underlying our
recommendations, and our response to MedPAC's recommendations
concerning the update factors.
I. Secretary's Final Recommendations for Updating the Prospective
Payment System Standardized Amounts
In recommending an update, the Secretary takes into account the
factors in the update framework, as well as the recommendations of
MedPAC, the long-term solvency of the Medicare Trust Funds, and the
capacity of the hospital industry to continually provide access to
high quality care to Medicare beneficiaries through adequate
reimbursement to health care providers.
We received several comments concerning our proposed
recommendation.
Comment: One commenter questioned the reason for the difference
between the 3.05 percent update to the standardized amounts
recommended by the Secretary to the Congress as printed in the May
4, 2001 proposed rule (65 FR 22885) and the 2.55 percent proposed
update used to establish the rates printed in the May 4, 2001
proposed rule (65 FR 22738).
Response: The President's FY 2002 budget estimated that the
market basket for FY 2002 would be 3.6 percent. This estimate is
prepared by the Office of Management and Budget (OMB) by applying
future assumptions of economy-wide wage and consumer price index
growth to the historical relationship between these factors and the
market basket.
The market basket we have historically used to actually update
the standardized amounts is estimated by our Office of the Actuary,
in conjunction with Global Insights, Inc., DRI-WEFA. Although this
estimate is generally very close to the OMB estimate, there are
often some discrepancies due to the timing of the estimate and the
differing future assumptions of the input factors.
Our final recommendation of the market basket percentage
increase minus 0.55 percentage points for the update for hospitals
subject to the prospective payment system, which is consistent with
current law, did not differ from the proposed. However, the second
quarter forecast of the market basket percentage increase is 3.3 for
prospective payment hospitals (up from 3.1 estimated in the proposed
rule). Thus, the Secretary's final recommendation is that the update
to the prospective payment system standardized amounts for both
large urban and other urban areas is 2.75 percent (or consistent
with current law, market basket percentage increase minus 0.55
percent). The update to the hospital-specific rate applicable to
SCHs and MDHs is also 2.75 percent (or consistent with current law,
market basket percentage increase minus 0.55 percentage points).
Comment: Several commenters addressed the recent increases in
the price of blood products. One commenter stated the increases
represent up to one percent of annual DRG payments for hospitals
that perform a significant number of surgeries. The commenters urged
us to ensure that the DRG payments reflect price increases
associated with rising blood prices.
Response: Section 301(c) of Public Law 106-554 requires the
Secretary to consider the price of blood and blood products in the
market basket index when the market basket is next rebased and
revised and to determine whether those prices are adequately
reflected.
III. Secretary's Final Recommendation for Updating the Rate-of-Increase
Limits for Excluded Hospitals and Units
We received no comments concerning our proposed recommendation.
Our final recommendation for excluded hospitals and units did not
differ from the proposed. However, the second quarter forecast of
the market basket percentage increase is 3.3 for excluded hospitals
and units (up from 3.0 estimated in the proposed rule). Thus, the
Secretary's final recommendation is that the update for hospitals
and units excluded from the prospective payment system can range
from market basket increase of 3.3 percent minus a percentage
between 0 and 2.5 percent, or 0 percent depending on the
relationship between the hospital's or unit's costs and its rate-of-
increase limit, which results in an increase in the rate-of-increase
limit between 0.8 and 3.3 percent, or 0 percent for FY 2002.
[FR Doc. 01-18868 Filed 7-31-01; 8:45 am]
BILLING CODE 4120-01-P