[Federal Register Volume 66, Number 190 (Monday, October 1, 2001)]
[Notices]
[Pages 49958-49964]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 01-24494]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1182-FN]
RIN 0938-AK75


Medicare Program; Revision of Payment Rates for End-Stage Renal 
Disease (ESRD) Patients Enrolled in Medicare+Choice Plans

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final notice.

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SUMMARY: This final notice establishes a new payment methodology, 
effective January 2002, for beneficiaries with End-Stage Renal Disease 
(ESRD) who are enrolled in Medicare+Choice (M+C) plans. This 
methodology implements section 605 of the Medicare, Medicaid, and SCHIP 
Benefits Improvement and Protection Act of 2000 (BIPA). Section 605 
requires the Secretary to increase M+C ESRD payment rates, using 
appropriate adjustments, to reflect the demonstration rates (including 
the risk adjustment methodology associated with those rates) of the 
social health maintenance organization (SHMO) ESRD capitation 
demonstrations. Briefly, the methodology set forth in this final 
notice--
    Increases the base year rates by 3 percent to reach 100 percent of 
fee-for-service costs as estimated for the base year for M+C purposes 
(this adopts the approach used under the ESRD SHMO demonstration); and
    Adjusts State per capita rates by age and sex factors, in order to 
pay more accurately, given differences in costs among ESRD patients.
    The effect of the new M+C ESRD payment methodology is to increase 
Medicare's fiscal year (FY) 2002 M+C ESRD payments by an estimated $35 
million (for 9 months of costs, given the effective date of January 
2002). M+C ESRD payment increases through FY 2006 are estimated to be 
$55 million for FY 2003, $55 million for FY 2004, $60 million for FY 
2005, and $65 million for FY 2006.
    The payment methodology set forth in this notice will govern M+C 
payments for enrollees with ESRD in 2002.

EFFECTIVE DATE: This final notice is effective January 1, 2002.
    For information on ordering copies of the Federal Register 
containing this document and electronic access, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Anne Hornsby, (410) 786-1181.

SUPPLEMENTARY INFORMATION:
    Copies: To order copies of the Federal Register containing this 
document, send your request to: New Orders, Superintendent of 
Documents, P.O. Box

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371954, Pittsburgh, PA 15250-7954. Specify the date of the issue 
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I. Background

    Section 605 of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (Pub. L. 106-554, enacted on 
December 21, 2000) (BIPA) amends section 1853(a)(1)(B) of the Social 
Security Act (the Act) by adding the following sentence at the end: 
``In establishing such rates, the Secretary shall provide for 
appropriate adjustments to increase each rate to reflect the 
demonstration rate (including the risk adjustment methodology 
associated with such rate) of the social health maintenance 
organization end-stage renal disease capitation demonstrations 
(established by section 2355 of the Deficit Reduction Act of 1984, as 
amended by section 13567(b) of the Omnibus Budget Reconciliation Act of 
1996), and shall compute such rates by taking into account such factors 
as renal treatment modality, age, and the underlying cause of the end-
stage renal disease.'' This amendment applies to payments for months 
beginning with January 2002.
    Currently, Medicare+Choice (M+C) end-stage renal disease (ESRD) 
capitation payments are based on State-level rates that are not risk-
adjusted. M+C ESRD base payment rates are based on the current M+C 
payment methodology, which builds on a base year (1997) amount 
representing 95 percent of projected State average fee-for-service 
costs, as determined at the time. M+C ESRD rates include the costs of 
beneficiaries with Medicare as Secondary Payer (MSP) and the costs of 
beneficiaries who have functioning grafts 3 years or less from date of 
transplant. Note that for the purpose of M+C payment, ``ESRD 
beneficiaries'' includes beneficiaries with ESRD, whether entitled to 
Medicare because of ESRD, disability, or age.
    On May 25, 2001, the Secretary announced that he will work closely 
with all interested parties to explore and implement a risk adjustment 
process for M+C payments that balances accuracy and administrative 
burden. The ESRD payment methodology falls under this review of our 
current risk adjustment system. For this reason, we will implement the 
age and sex adjusters for calendar year (CY) 2002, while continuing to 
review other options for subsequent years, including those suggested by 
the commenters on the proposed notice.

A. ESRD Managed Care Demonstration Project

    Beneficiaries with ESRD are the only group eligible for benefits 
under Parts A and B who are prohibited from enrolling in M+C 
organizations, although a beneficiary who develops ESRD after enrolling 
with an organization that offers an M+C plan may remain enrolled with 
the organization under an M+C plan. In 1993, the Congress required the 
Secretary to conduct an ESRD Managed Care Demonstration Project to 
assess whether it is feasible to allow enrollment in managed care for 
Medicare ESRD patients of all ages and to test risk-adjusted capitation 
for ESRD beneficiaries. As of December 2000, there were two such 
Demonstration sites, one in California with approximately 1,200 
enrollees and a second in Florida with approximately 600 enrollees.
    The ESRD Demonstration introduced 100 percent risk-adjustment into 
ESRD capitation payments. We calculated separate monthly capitation 
rates by treatment modality (dialysis, transplant, or functioning 
graft), and then adjusted the dialysis and functioning graft rates for 
age (0-19, 20-64, or 65+ years old) and original cause of renal failure 
(diabetes or other cause).
    Further, the Demonstration tested whether offering additional 
benefits not covered by Medicare enhanced effective treatment of this 
population. The statute mandated that we pay ESRD Demonstration sites 
100 percent of estimated per capita fee-for-service expenditures in 
that State, rather than the 95 percent of this same amount that was 
paid to managed care plans outside the Demonstration. To justify the 
extra 5 percent, ESRD Demonstration sites agreed to provide additional 
benefits, for example, nutritional supplements.
    Finally, the Demonstration did not allow ESRD patients with MSP 
status to enroll in the sites. Therefore, we excluded fee-for-service 
beneficiaries with MSP from calculation of the base payment rates. 
Excluding MSP beneficiaries increased the Demonstration rates about 20 
percent over rates paid outside the Demonstration.

B. ESRD Demonstration Experience With the Capitated Payment System

    Preliminary assessments revealed that the administrative demands of 
implementing the risk adjustment methodology employed in the ESRD 
Demonstration were substantial and complex. CMS and the Demonstration 
sites experienced difficulty with ensuring accurate and timely 
collection of data on treatment modality; data problems also occurred 
with the original cause adjuster. In large part, this was because we 
had to rely on nonbilling documents to determine payment status. For 
example, the documentation of a transplant involves a detailed medical 
form that must travel from transplant center to organ transplant 
network to us. Often we did not receive these forms timely. Working 
with the earlier years of the Demonstration sites, we had to create 
complex processes for retroactive adjustments and reconciliations 
because of delays in receipt of the appropriate documentation.
    This preliminary assessment is based on our analysis of issues that 
arose during the ESRD Demonstration. The final evaluation of the ESRD 
Demonstration is forthcoming. Meanwhile, we are pursuing further 
improvements to the payment system for ESRD beneficiaries enrolled in 
managed care. The ESRD Demonstration has received an extension until 
January 1, 2002. Under the terms of the extension granted to the two 
sites, an unadjusted capitation rate is paid (in contrast to the 
demonstration, for which rates were risk-adjusted). The extensions are 
scheduled to terminate December 31, 2001. At that time, the residual 
demonstration enrollees will be transitioned into the organizations' 
M+C plans and the extension methodology will be superseded by 
implementation of the new M+C ESRD payment methodology set forth in 
this notice.

II. Provisions of the Proposed Notice

    On May 1, 2001, we published a proposed notice in the Federal 
Register (66 FR 21770) that proposed to establish a new payment 
methodology, effective January 2002, for beneficiaries with ESRD who 
are enrolled in M+C plans. The discussion below summarizes the 
provisions of that notice.

[[Page 49960]]

A. Calculation of State-Level Per Capita ESRD Rates at 100 Percent of 
State Fee-for-Service Costs

    The BIPA requires that M+C ESRD rates be increased to reflect the 
Demonstration rates. We discussed our approach to reflecting the 
Demonstration base rate calculations in section II.A. of the May 1, 
2001 proposed notice. To summarize, we proposed to increase the 1997 
base rate produced by the pre-BIPA M+C ESRD payment methodology by 
approximately 1 percent to get to 100 percent of actual fee-for-service 
costs for 1997, thus fulfilling the BIPA mandate that new ESRD rates be 
increased to reflect the Demonstration rates, which are based on a 100 
percent standard.
     Our analysis of the 1997 rates reveals that the national 
per capita rate promulgated in 1997 (based on September 1996 
calculations) is about 4.1 percent higher than our current best 
estimate of the actual 1997 fee-for-service costs on which the rates 
are based.
     Under the M+C methodology set forth in the Balanced Budget 
Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997) (BBA), the 
original 1997 rates were the basis for all future rates, with no 
provision for correcting over or under estimates for that year. This 
means that, on average, in 1997, we paid managed care organizations an 
amount representing about 99 percent of the actual Medicare Average 
Annual Per Capita Cost (AAPCC) for 1997, rather than the assumed 95 
percent of the AAPCC.
    To pay M+C organizations 100 percent of estimated State per capita 
ESRD fee-for-service costs for 1997, therefore, we proposed to increase 
the 1997 rates by approximately 1 percent.
    See Section II.A. of the proposed notice HCFA-1182-PN (66 FR 21770) 
for an in-depth discussion of the rationale behind our proposed 
approach to paying 100 percent of State fee-for-service costs in a base 
year.

B. Risk Adjustment of the Base Payment Rates by Age and Sex

    As noted above, section 605 of BIPA requires that the increase in 
ESRD rates to reflect Demonstration rates include the risk adjustment 
methodology associated with those rates. The methodology in place at 
the time the BIPA was enacted is set forth above in section I.A. Also 
see Section II.B. of the proposed notice for discussion of our approach 
to risk adjustment of M+C ESRD payments.
    We proposed to adjust M+C ESRD rates only for age and sex. We 
believe that this reflects the most significant effects of the ESRD 
Demonstration methodology in effect at the time of the BIPA. Our 
reasons are presented below. While the Demonstration methodology 
included several components, the bulk of the effect of risk adjustment 
is attributable to adjustment for age. To increase the power of the age 
adjustment compared to the ESRD Demonstration age adjustment, we are 
changing from a 3-category age classification to the 10-category 
classification currently used in the M+C payment methodology.
    We decided not to create separate rates for treatment modality or 
adjust for original cause of kidney failure for several reasons. In the 
proposed notice, we indicated that when we implement the comprehensive 
risk adjustment model (adding ambulatory and outpatient diagnoses to 
the existing hospital-diagnosis system), we would incorporate M+C ESRD 
enrollees into the single risk-adjusted payment system. This allows us 
to capture co-morbidity information in addition to demographic 
information and basic disease markers for ESRD beneficiaries.
    In addition, research indicates that increased age is the single 
best correlate of ESRD mortality. The ESRD population enrolled in 
managed care is on average older than the ESRD fee-for-service 
population (see table below). (This is due to the current restrictions 
on ESRD enrollment in M+C organizations.) Our research comparing the 
1998 Medicare HMO ESRD population with the fee-for-service population 
reveals the following contrasts (Eggers 2000).

------------------------------------------------------------------------
                                                            Percent of
                                            Percent of     ESRD fee-for-
                   Age                       ESRD HMO         service
                                            population      population
------------------------------------------------------------------------
Age 75+.................................              28              15
65-74...................................              41              22
45-64...................................              24              39
0-44....................................               7              24
------------------------------------------------------------------------

    We reviewed other evidence before selecting an interim risk 
adjustment methodology based on age and sex, including the following:
     Eggers et al. (2001) found that when taking age into 
account, M+C organizations were transplanting at the same rates as fee-
for-service organizations in 1998.
     A detailed study of capitation models for ESRD (The Lewin 
Group and URREA 2000) showed that age is a much more important factor 
predicting 1996 fee-for-service spending for within-year transplant 
patients, functioning graft patients, and pediatric dialysis patients 
than it is for adult hemodialysis patients. The study noted, however, 
that ESRD patients enrolled in Medicare HMOs with Medicare as primary 
payer are not included in the sample of patients analyzed, so we do not 
know whether the study findings are accurate for the M+C ESRD 
population, which is on average older than the fee-for-service ESRD 
population.
    Taking into consideration the current enrollment restrictions in 
the M+C program and the resulting age distribution of M+C ESRD 
enrollees, we concluded that adjusting for age and sex and using a more 
detailed age categorization obviates the need to include treatment 
modality and original cause as factors in this interim methodology. We 
also stated in the proposed notice that a change in the law to allow 
ESRD beneficiaries of all ages to enroll in M+C plans would result in 
moderation of the average payment increases expected from the proposed 
methodology. Preliminary findings from the ESRD Demonstration, which 
allowed ESRD beneficiaries of all ages to enroll, indicate that the age 
distributions at the Demonstration sites were very similar to the ESRD 
age distribution in fee-for-service Medicare. Thus, under open 
enrollment, we would expect a shift in the age distribution of the M+C 
ESRD population toward younger enrollees.
    The proposed notice also stated that, although the ESRD Managed 
Care Demonstration did not allow beneficiaries with MSP to enroll, we 
are unable to exclude from the M+C program any beneficiaries with MSP 
who develop ESRD. Therefore, these ESRD beneficiaries with MSP will be

[[Page 49961]]

included in the program and payment rates. Due to data limitations, we 
noted that we did not expect to make separate payment adjustments.

III. Analysis of and Responses to Public Comments on the May 1, 
2001, Proposed Notice

    We received 6 items of correspondence containing a variety of 
comments on the proposed ESRD payment methodology. Commenters included 
managed care organizations and other industry representatives, 
representatives of physicians and other health care professionals, a 
research organization, and beneficiary advocacy groups. The comments 
concerned both parts of the proposed methodology: the 1 percent 
increase in the 1997 base year rate and the risk adjusters that we 
proposed.
    Comment: Some commenters objected to our proposal to increase the 
ESRD State base rates by only 1 percent.
    In particular, they recommended that, to increase the base payment 
rates from 95 percent to 100 percent of the average adjusted per capita 
cost (AAPCC), CMS should increase the 1997 State per capita M+C ESRD 
rates by 5.26 percent (100/95 = 1.0526).
    Response: We have reviewed the arguments supporting the 1 percent 
increase, which were set forth in the proposed notice and summarized 
above, and the commenters' argument in favor of a 5.26 percent 
increase. We also have reviewed the terms and conditions of the ESRD 
Demonstration. As provided in section 2355 of the Deficit Reduction Act 
of 1984, as amended by section 13567(b) of the Omnibus Budget 
Reconciliation Act of 1996, which mandated the SHMO Demonstration, 
payment was to be based on 100 percent of estimated per capita fee-for-
service expenditures in Demonstration States, rather than the 95 
percent of this same amount that was paid to managed care plans outside 
the Demonstration. To justify the extra 5 percent, ESRD Demonstration 
sites were required to provide additional non-Medicare covered benefits 
especially needed by the ESRD population, for example, nutritional 
supplements. The ESRD Demonstration received an extension until January 
1, 2002. Under the terms of the extension, the two sites must continue 
to offer the additional benefits.
    While the approach we presented in our proposed notice would 
reflect the original Demonstration rates in that it would pay 100 
percent of our best estimate of fee-for-service costs, the approach 
recommended by the commenters would come closer to paying the base rate 
amounts actually paid under the ESRD Demonstration. The BIPA statute 
requires that ``appropriate'' adjustments be made to ``reflect'' the 
demonstration rates, not necessarily that all M+C organizations be paid 
the amounts paid under the ESRD Demonstration. Even if one were to 
accept the commenters' premise that payment should be closer to the 
amounts paid under the Demonstration (rather than our proposal, which 
more accurately reflects the payment standard provided for in the SHMO 
demonstration statute), we have determined that a full 5.26 percent 
increase in the base rates would not be appropriate. This is because 
the additional benefits required under the Demonstration cannot be 
required of M+C plans outside this Demonstration, and at least some 
portion of the additional 5.26 percent paid under the ESRD 
Demonstration can be attributable to these additional benefits.
    Accordingly, we have decided that a midpoint between our proposed 1 
percent increase and the commenters' suggested 5.26 percent increase in 
the base rates is the most appropriate proxy for 100 percent of 
estimated per capita fee-for-service expenditures for ESRD 
beneficiaries, and thus the most appropriate way to ``reflect'' the 
Demonstration rates. Therefore, CMS will increase the ESRD base rates 
by 3 percent. This increase reflects the Demonstration methodology, and 
acknowledges that CMS cannot require M+C plans outside this 
Demonstration to offer the additional benefits that we required in the 
Demonstration in exchange for capitation rates set at 100 percent of 
fee-for-service costs. The 3 percent increase also represents the 
middle ground between two reasonable interpretations of the statute.
    Comment: Although commenters were pleased that CMS will introduce 
age and sex risk adjusters into M+C ESRD payments beginning in 2002, 
all expressed concern that CMS was not using additional adjusters in 
order to pay more accurately for high severity cases. In particular, 
all commenters suggested that we add some combination of the following 
adjusters: whether diabetes is original cause of ESRD, treatment status 
(dialysis, transplant, post-transplant functioning graft), and Medicare 
Secondary Payer (MSP) status.
    Response: On May 25, 2001, the Secretary announced that he will 
work closely with all interested parties to explore and implement a 
risk adjustment process for M+C payments that balances accuracy and 
administrative burden. The ESRD payment methodology falls under this 
review of our current risk adjustment system. For this reason, we will 
implement the age and sex adjusters for calendar year (CY) 2002, while 
continuing to review other options for subsequent years, including 
those suggested by the commenters on the proposed notice. We recognize 
that MSP status is an issue, and we plan to explore options within our 
payment system. We also plan to explore the feasibility of payment 
areas for ESRD enrollees that are smaller than States.
    Meanwhile, the age and sex factors for ESRD beneficiaries enrolled 
in M+C plans that were developed by CMS's OACT and published in the 
proposed notice will be used in making payments for ESRD beneficiaries 
starting in January 1, 2002.

IV. Provisions of the Final Notice

    We increased the 1997 M+C ESRD State rates by 3.00 percent, and 
then updated the rates to CY 2002 using the BBA methodology, which 
resulted in the minimum percentage increase each subsequent year. We 
will adjust payments with age and sex factors.
    Below are two tables presenting the State M+C ESRD rates for CY 
2002 and the age/sex factors for calculating M+C ESRD enrollee 
payments. In the first table, Average DF refers to Average Demographic 
Factor. Under the provisions of this notice, the Average DFs are 
average age/sex factors per State for Part A and Part B. ``New 2002 
rates'' refer to the ESRD rates that follow from the BIPA mandate and 
will be implemented January 1, 2002. They are statewide rates 
standardized by State average DFs (average age and sex factors) and 
increased by 3.00 percent.

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                               Age/Sex Demographic Factors for M+C ESRD Enrollees
----------------------------------------------------------------------------------------------------------------
                                                              Part A                          Part B
                       Age                       ---------------------------------------------------------------
                                                       Male           Female           Male           Female
----------------------------------------------------------------------------------------------------------------
0-34............................................             .55             .70             .70             .75
35-44...........................................             .65             .70             .80             .80
45-54...........................................             .70             .85             .85             .90
55-59...........................................             .80             .95             .90            1.00
60-64...........................................             .90            1.10             .90            1.10
65-69...........................................            1.15            1.35            1.10            1.20
70-74...........................................            1.25            1.45            1.15            1.25
75-79...........................................            1.30            1.55            1.20            1.25
80-84...........................................            1.40            1.60            1.20            1.25
85+.............................................            1.45            1.60            1.20            1.25
----------------------------------------------------------------------------------------------------------------

    To calculate the payment for a given ESRD enrollee, multiply the 
appropriate age/sex factors by the standardized statewide M+C ESRD 
payment rates in the table. (Prior to January 2002, there are no 
adjustments for age and sex for M+C ESRD beneficiaries.)
    Given current enrollment restrictions, we estimate that, under this 
methodology, the age- and sex-adjusted average ESRD payment per 
beneficiary will result in a significant increase in payments to M+C 
organizations for their ESRD enrollees.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

VI. Regulatory Impact Statement

    We have examined the impacts of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review) and the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Public Law 96-
354). Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more annually).
    We have determined that this final notice is not a major rule with 
economically significant effects. There are approximately 18,000 ESRD 
beneficiaries enrolled in M+C plans. The additional cash expenditures 
for these M+C ESRD beneficiaries under this BIPA provision are 
estimated to be: $35 million in Fiscal Year (FY) 2002; $55 million in 
FY 2003; $55 million in FY 2004; $60 million in FY 2005; and $65 
million in FY 2006. These estimates assume continuation of the current 
restrictions on enrollment in the M+C program for ESRD beneficiaries. 
These estimates include the impact of adjusting for age and sex and the 
impact of raising the ESRD base rates by 3.00 percent. Since this final 
notice results in increases in total expenditures of less than $100 
million per year, this notice is not a major rule as defined in Title 
5, United States Code, section 804(2) and is not an economically 
significant rule under Executive Order 12866.
    The RFA requires agencies to analyze the economic impact on small 
entities, and if an agency finds that a regulation imposes a 
significant burden on a substantial number of small entities, it must 
explore options for reducing the burden. For purposes of the RFA, small 
entities include small businesses, nonprofit organizations, and

[[Page 49964]]

government agencies. Most hospitals and most other providers and 
suppliers are small entities, either by nonprofit status or by having 
revenues of $7.5 million or less annually. For purposes of the RFA, 
most managed care organizations are not considered to be small 
entities. Individuals and States are not included in the definition of 
a small entity.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a Metropolitan 
Statistical Area and has fewer than 100 beds.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in expenditure in any one year by 
State, local, or tribal governments, in the aggregate, or by the 
private sector, of $110 million. This final notice will have no 
consequential effect on State, local, or tribal governments, and the 
private sector cost of this rule falls below these thresholds as well.
    We have reviewed this final notice under the threshold criteria of 
E.O. 13132, Federalism. We have determined that this final notice will 
not significantly affect the rights, roles, and responsibilities of the 
States.
    We have examined the economic impact of this notice on M+C 
organizations and find that the overall impact is positive. However, 
because the number of ESRD patients enrolled in M+C organizations 
represents a very small fraction of M+C organizations' annual receipts, 
and because a small number of M+C organizations qualify as small 
entities under the RFA, the Secretary is certifying that this notice 
will not have a significant impact on a substantial number of small 
entities. To our knowledge, no small rural hospitals will be affected 
by this notice, so the Secretary is also certifying that this notice 
will not have a significant impact on a substantial number of small 
rural hospitals.
    In accordance with the provisions of E.O. 12866, this final notice 
was reviewed by OMB.

Works Cited

Eggers, Paul W., Diane L. Frankenfield, Joel W. Greer, William 
McClellan, William F. Owen, Jr., and Michael V. Rocco, ``Comparison of 
Mortality and Intermediate Outcomes between Dialysis Patients Enrolled 
in HMO and Fee for Service,'' February 2001. Under review at the 
American Journal of Kidney Disease.
Eggers, Paul. ``Outcome of ESRD Patients in HMOs.'' RPA/REF 2000 Annual 
Meeting. Washington D.C. March 25-27, 2000.
The Lewin Group and University Renal Research and Education Association 
(URREA). ``Capitation Models for ESRD: Methodology and Results.'' 
Prepared for Renal Physicians Association, American Society of 
Nephrology, American Society of Transplant Physicians, American Society 
for Pediatric Nephrology, and Amgen. January 7, 2000.

Section 1853(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w-
23(a)(1)(B))

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare-Hospital Insurance; and Program No. 93.774, Medicare-
Supplementary Medical Insurance Program)

    Dated: July 30, 2001.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: August 16, 2001.
Tommy G. Thompson,
Secretary.
[FR Doc. 01-24494 Filed 9-28-01; 8:45 am]
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