[Federal Register Volume 75, Number 83 (Friday, April 30, 2010)]
[Notices]
[Pages 23106-23149]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-9870]
[[Page 23105]]
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Part IV
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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Medicare Program; Inpatient Psychiatric Facilities Prospective Payment
System Payment--Update for Rate Year Beginning July 1, 2010 (RY 2011);
Notice
Federal Register / Vol. 75 , No. 83 / Friday, April 30, 2010 /
Notices
[[Page 23106]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1424-N]
RIN 0938-AP83
Medicare Program; Inpatient Psychiatric Facilities Prospective
Payment System Payment--Update for Rate Year Beginning July 1, 2010 (RY
2011)
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice
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SUMMARY: This notice updates the payment rates for the Medicare
prospective payment system (PPS) for inpatient psychiatric hospital
services provided by inpatient psychiatric facilities (IPFs). These
changes are applicable to IPF discharges occurring during the rate year
beginning July 1, 2010 through June 30, 2011. We are also responding to
comments on the IPF PPS teaching adjustment and the market basket,
which we received in response to our May 2009 IPF PPS notice with
request for comments.
DATES: Effective Date: The updated IPF prospective payment rates are
effective for discharges occurring on or after July 1, 2010 through
June 30, 2011.
FOR FURTHER INFORMATION CONTACT:
Dorothy Myrick or Jana Lindquist, (410) 786-4533 (for general
information).
Mary Carol Barron, (410) 786-7943 (for information regarding the market
basket and labor-related share).
Theresa Bean, (410) 786-2287 (for information regarding the regulatory
impact analysis).
SUPPLEMENTARY INFORMATION:
Table of Contents
To assist readers in referencing sections contained in this
document, we are providing the following table of contents.
I. Background
A. Annual Requirements for Updating the IPF PPS
B. Overview of the Legislative Requirements of the IPF PPS
C. IPF PPS--General Overview
II. Transition Period for Implementation of the IPF PPS
III. Updates to the IPF PPS for RY Beginning July 1, 2010
A. Determining the Standardized Budget-Neutral Federal Per Diem
Base Rate
1. Standardization of the Federal Per Diem Base Rate and
Electroconvulsive Therapy (ECT) Rate
2. Calculation of the Budget Neutrality Adjustment
a. Outlier Adjustment
b. Stop-Loss Provision Adjustment
c. Behavioral Offset
B. Update of the Federal Per Diem Base Rate and
Electroconvulsive Therapy Rate
1. Market Basket for IPFs Reimbursed under the IPF PPS
a. Market Basket Index for the IPF PPS
b. Overview of the RPL Market Basket
2. Labor-Related Share
3. Comments on Creating a Stand-Alone IPF Market Basket
IV. Update of the IPF PPS Adjustment Factors
A. Overview of the IPF PPS Adjustment Factors
B. Patient-Level Adjustments
1. Adjustment for MS-DRG Assignment
2. Payment for Comorbid Conditions
3. Patient Age Adjustments
4. Variable Per Diem Adjustments
C. Facility-Level Adjustments
1. Wage Index Adjustment
a. Background
b. Wage Index for RY 2011
c. OMB Bulletins
2. Adjustment for Rural Location
3. Teaching Adjustment
4. Cost of Living Adjustment for IPFs Located in Alaska and
Hawaii
5. Adjustment for IPFs With a Qualifying Emergency Department
(ED)
D. Other Payment Adjustments and Policies
1. Outlier Payments
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
b. Statistical Accuracy of Cost-to-Charge Ratios
2. Expiration of the Stop-Loss Provision
V. Comments Beyond the Scope of the May 2009 IPF PPS Notice With
Request for Comments
VI. Waiver of Proposed Rulemaking
VII. Collection of Information Requirements
VIII. Regulatory Impact Analysis
Addenda
Acronyms
Because of the many terms to which we refer by acronym in this
notice, we are listing the acronyms used and their corresponding terms
in alphabetical order below:
BBRA Medicare, Medicaid and SCHIP [State Children's Health Insurance
Program] Balanced Budget Refinement Act of 1999, (Pub. L. 106-113).
CBSA Core-Based Statistical Area.
CCR Cost-to-charge ratio.
CAH Critical access hospital.
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition--Text Revision.
DRGs Diagnosis-related groups.
FY Federal fiscal year.
ICD-9-CM International Classification of Diseases, 9th Revision,
Clinical Modification.
IPFs Inpatient psychiatric facilities.
IRFs Inpatient rehabilitation facilities.
LTCHs Long-term care hospitals.
MedPAR Medicare provider analysis and review file.
RY Rate Year.
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, (Pub. L. 97-
248).
I. Background
A. Annual Requirements for Updating the IPF PPS
In November 2004, we implemented the inpatient psychiatric
facilities (IPF) prospective payment system (PPS) in a final rule that
appeared in the November 15, 2004 Federal Register (69 FR 66922). In
developing the IPF PPS, in order to ensure that the IPF PPS is able to
account adequately for each IPF's case-mix, we performed an extensive
regression analysis of the relationship between the per diem costs and
certain patient and facility characteristics to determine those
characteristics associated with statistically significant cost
differences on a per diem basis. For characteristics with statistically
significant cost differences, we used the regression coefficients of
those variables to determine the size of the corresponding payment
adjustments.
In that final rule, we explained that we believe it is important to
delay updating the adjustment factors derived from the regression
analysis until we have IPF PPS data that includes as much information
as possible regarding the patient-level characteristics of the
population that each IPF serves. Therefore, we indicated that we did
not intend to update the regression analysis and recalculate the
Federal per diem base rate and the patient- and facility-level
adjustments until we complete that analysis. Until that analysis is
complete, we stated our intention to publish a notice in the Federal
Register each spring to update the IPF PPS (71 FR 27041).
Updates to the IPF PPS as specified in 42 CFR Sec. 412.428 include
the following:
A description of the methodology and data used to
calculate the updated Federal per diem base payment amount.
The rate of increase factor as described in Sec.
412.424(a)(2)(iii), which is based on the excluded hospital with
capital market basket under the update methodology of section
1886(b)(3)(B)(ii) of the Social Security Act (the Act) for each year
(effective from the implementation period until June 30, 2006).
For discharges occurring on or after July 1, 2006, the
rate of increase factor for the Federal portion of the IPF's payment,
which is based on the rehabilitation, psychiatric, and long-term care
(RPL) market basket.
The best available hospital wage index and information
regarding whether an adjustment to the Federal
[[Page 23107]]
per diem base rate is needed to maintain budget neutrality.
Updates to the fixed dollar loss threshold amount in order
to maintain the appropriate outlier percentage.
Description of the International Classification of
Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding and
diagnosis-related groups (DRGs) classification changes discussed in the
annual update to the hospital inpatient prospective payment system
(IPPS) regulations.
Update to the electroconvulsive therapy (ECT) payment by a
factor specified by CMS.
Update to the national urban and rural cost-to-charge
ratio medians and ceilings.
Update to the cost of living adjustment factors for IPFs
located in Alaska and Hawaii, if appropriate.
Our most recent annual update occurred in the May 2009 IPF PPS
notice with request for comments (74 FR 20362) (hereinafter referred to
as the May 2009 IPF PPS notice) that set forth updates to the IPF PPS
payment rates for RY 2010. This notice updates the IPF per diem payment
rates that were published in the May 2009 IPF PPS notice in accordance
with our established policies.
B. Overview of the Legislative Requirements of the IPF PPS
Section 124 of the Medicare, Medicaid, and SCHIP (State Children's
Health Insurance Program) Balanced Budget Refinement Act of 1999, (Pub.
L. 106-113) (BBRA) required implementation of the IPF PPS.
Specifically, section 124 of the BBRA mandated that the Secretary
develop a per diem PPS for inpatient hospital services furnished in
psychiatric hospitals and psychiatric units that includes an adequate
patient classification system that reflects the differences in patient
resource use and costs among psychiatric hospitals and psychiatric
units.
Section 405(g)(2) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF
PPS to distinct part psychiatric units of critical access hospitals
(CAHs).
To implement these provisions, we published various proposed and
final rules in the Federal Register. For more information regarding
these rules, see the CMS Web sites http://www.cms.hhs.gov/InpatientPsychFacilPPS/and http://www.cms.hhs.gov/InpatientpsychfacilPPS/02_regulations.asp.
Section 1886(s)(3)(A) of the Act, which was added by Section
3401(f) of the Patient Protection and Affordable Care Act (Pub. L. 111-
148) as amended by Section 10319(e) of that Act and by Section 1105 of
the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-
152), requires the application of an ``Other Adjustment'' that reduces
any update to the IPF PPS base rate by 0.25 percentage point for the
rate year beginning in 2010. We are implementing that provision for RY
2011 in this notice.
C. IPF PPS--General Overview
The November 2004 IPF PPS final rule (69 FR 66922) established the
IPF PPS, as authorized under section 124 of the BBRA and codified at
subpart N of part 412 of the Medicare regulations. The November 2004
IPF PPS final rule set forth the per diem Federal rates for the
implementation year (the 18-month period from January 1, 2005 through
June 30, 2006), and it provided payment for the inpatient operating and
capital costs to IPFs for covered psychiatric services they furnish
(that is, routine, ancillary, and capital costs, but not costs of
approved educational activities, bad debts, and other services or items
that are outside the scope of the IPF PPS). Covered psychiatric
services include services for which benefits are provided under the
fee-for-service Part A (Hospital Insurance Program) Medicare program.
The IPF PPS established the Federal per diem base rate for each
patient day in an IPF derived from the national average daily routine
operating, ancillary, and capital costs in IPFs in FY 2002. The average
per diem cost was updated to the midpoint of the first year under the
IPF PPS, standardized to account for the overall positive effects of
the IPF PPS payment adjustments, and adjusted for budget neutrality.
The Federal per diem payment under the IPF PPS is comprised of the
Federal per diem base rate described above and certain patient- and
facility-level payment adjustments that were found in the regression
analysis to be associated with statistically significant per diem cost
differences.
The patient-level adjustments include age, DRG assignment,
comorbidities, and variable per diem adjustments to reflect higher per
diem costs in the early days of an IPF stay. Facility-level adjustments
include adjustments for the IPF's wage index, rural location, teaching
status, a cost of living adjustment for IPFs located in Alaska and
Hawaii, and presence of a qualifying emergency department (ED).
The IPF PPS provides additional payment policies for: outlier
cases; stop-loss protection (which was applicable only during the IPF
PPS transition period); interrupted stays; and a per treatment
adjustment for patients who undergo ECT.
A complete discussion of the regression analysis appears in the
November 2004 IPF PPS final rule (69 FR 66933 through 66936).
Section 124 of BBRA does not specify an annual update rate strategy
for the IPF PPS and is broadly written to give the Secretary discretion
in establishing an update methodology. Therefore, in the November 2004
IPF PPS final rule, we implemented the IPF PPS using the following
update strategy:
Calculate the final Federal per diem base rate to be
budget neutral for the 18-month period of January 1, 2005 through June
30, 2006.
Use a July 1 through June 30 annual update cycle.
Allow the IPF PPS first update to be effective for
discharges on or after July 1, 2006 through June 30, 2007.
II. Transition Period for Implementation of the IPF PPS
In the November 2004 IPF PPS final rule, we provided for a 3-year
transition period. During this 3-year transition period, an IPF's total
payment under the PPS was based on an increasing percentage of the
Federal rate with a corresponding decreasing percentage of the IPF PPS
payment that is based on reasonable cost concepts. However, effective
for cost reporting periods beginning on or after January 1, 2008, IPF
PPS payments are based on 100 percent of the Federal rate.
III. Updates to the IPF PPS for RY Beginning July 1, 2010
The IPF PPS is based on a standardized Federal per diem base rate
calculated from IPF average per diem costs and adjusted for budget-
neutrality in the implementation year. The Federal per diem base rate
is used as the standard payment per day under the IPF PPS and is
adjusted by the patient- and facility-level adjustments that are
applicable to the IPF stay. A detailed explanation of how we calculated
the average per diem cost appears in the November 2004 IPF PPS final
rule (69 FR 66926).
A. Determining the Standardized Budget-Neutral Federal Per Diem Base
Rate
Section 124(a)(1) of the BBRA requires that we implement the IPF
PPS in a budget neutral manner. In other words, the amount of total
payments
[[Page 23108]]
under the IPF PPS, including any payment adjustments, must be projected
to be equal to the amount of total payments that would have been made
if the IPF PPS were not implemented. Therefore, we calculated the
budget-neutrality factor by setting the total estimated IPF PPS
payments to be equal to the total estimated payments that would have
been made under the Tax Equity and Fiscal Responsibility Act of 1982
(TEFRA) (Pub. L. 97-248) methodology had the IPF PPS not been
implemented.
Under the IPF PPS methodology, we calculated the final Federal per
diem base rate to be budget neutral during the IPF PPS implementation
period (that is, the 18-month period from January 1, 2005 through June
30, 2006) using a July 1 update cycle. We updated the average cost per
day to the midpoint of the IPF PPS implementation period (that is,
October 1, 2005), and this amount was used in the payment model to
establish the budget-neutrality adjustment.
A step-by-step description of the methodology used to estimate
payments under the TEFRA payment system appears in the November 2004
IPF PPS final rule (69 FR 66926).
1. Standardization of the Federal Per Diem Base Rate and
Electroconvulsive Therapy (ECT) Rate
In the November 2004 IPF PPS final rule, we describe how we
standardized the IPF PPS Federal per diem base rate in order to account
for the overall positive effects of the IPF PPS payment adjustment
factors. To standardize the IPF PPS payments, we compared the IPF PPS
payment amounts calculated from the FY 2002 Medicare Provider Analysis
and Review (MedPAR) file to the projected TEFRA payments from the FY
2002 cost report file updated to the midpoint of the IPF PPS
implementation period (that is, October 2005). The standardization
factor was calculated by dividing total estimated payments under the
TEFRA payment system by estimated payments under the IPF PPS. The
standardization factor was calculated to be 0.8367.
As described in detail in the May 2006 IPF PPS final rule (71 FR
27045), in reviewing the methodology used to simulate the IPF PPS
payments used for the November 2004 IPF PPS final rule, we discovered
that due to a computer code error, total IPF PPS payments were
underestimated by about 1.36 percent. Since the IPF PPS payment total
should have been larger than the estimated figure, the standardization
factor should have been smaller (0.8254 vs. 0.8367). In turn, the
Federal per diem base rate and the ECT rate should have been reduced by
0.8254 instead of 0.8367.
To resolve this issue, in RY 2007, we amended the Federal per diem
base rate and the ECT payment rate prospectively. Using the
standardization factor of 0.8254, the average cost per day was
effectively reduced by 17.46 percent (100 percent minus 82.54 percent =
17.46 percent).
2. Calculation of the Budget Neutrality Adjustment
To compute the budget neutrality adjustment for the IPF PPS, we
separately identified each component of the adjustment, that is, the
outlier adjustment, stop-loss adjustment, and behavioral offset.
A complete discussion of how we calculate each component of the
budget neutrality adjustment appears in the November 2004 IPF PPS final
rule (69 FR 66932 through 66933) and in the May 2006 IPF PPS final rule
(71 FR 27044 through 27046).
a. Outlier Adjustment
Since the IPF PPS payment amount for each IPF includes applicable
outlier amounts, we reduced the standardized Federal per diem base rate
to account for aggregate IPF PPS payments estimated to be made as
outlier payments. The outlier adjustment was calculated to be 2
percent. As a result, the standardized Federal per diem base rate was
reduced by 2 percent to account for projected outlier payments.
b. Stop-Loss Provision Adjustment
As explained in the November 2004 IPF PPS final rule, we provided a
stop-loss payment during the transition from cost-based reimbursement
to the per diem payment system to ensure that an IPF's total PPS
payments were no less than a minimum percentage of their TEFRA payment,
had the IPF PPS not been implemented. We reduced the standardized
Federal per diem base rate by the percentage of aggregate IPF PPS
payments estimated to be made for stop-loss payments. As a result, the
standardized Federal per diem base rate was reduced by 0.39 percent to
account for stop-loss payments. Since the transition was completed in
RY 2009, the stop-loss provision is no longer applicable, and for cost
reporting periods beginning on or after January 1, 2008, IPFs were paid
100 percent PPS.
c. Behavioral Offset
As explained in the November 2004 IPF PPS final rule,
implementation of the IPF PPS may result in certain changes in IPF
practices, especially with respect to coding for comorbid medical
conditions. As a result, Medicare may make higher payments than assumed
in our calculations. Accounting for these effects through an adjustment
is commonly known as a behavioral offset.
Based on accepted actuarial practices and consistent with the
assumptions made in other PPSs, we assumed in determining the
behavioral offset that IPFs would regain 15 percent of potential
``losses'' and augment payment increases by 5 percent. We applied this
actuarial assumption, which is based on our historical experience with
new payment systems, to the estimated ``losses'' and ``gains'' among
the IPFs. The behavioral offset for the IPF PPS was calculated to be
2.66 percent. As a result, we reduced the standardized Federal per diem
base rate by 2.66 percent to account for behavioral changes. As
indicated in the November 2004 IPF PPS final rule, we do not plan to
change adjustment factors or projections until we analyze IPF PPS data.
If we find that an adjustment is warranted, the percent difference
may be applied prospectively to the established PPS rates to ensure the
rates accurately reflect the payment level intended by the statute. In
conducting this analysis, we will be interested in the extent to which
improved coding of patients' principal and other diagnoses, which may
not reflect real increases in underlying resource demands, has occurred
under the PPS.
B. Update of the Federal Per Diem Base Rate and Electroconvulsive
Therapy Rate
1. Market Basket for IPFs Reimbursed under the IPF PPS
As described in the November 2004 IPF PPS final rule (69 FR 66931),
the average per diem cost was updated to the midpoint of the
implementation year. This updated average per diem cost of $724.43 was
reduced by 17.46 percent to account for standardization to projected
TEFRA payments for the implementation period, by 2 percent to account
for outlier payments, by 0.39 percent to account for stop-loss
payments, and by 2.66 percent to account for the behavioral offset. The
Federal per diem base rate in the implementation year was $575.95. The
increase in the per diem base rate for RY 2009 included the 0.39
percent increase due to the removal of the stop-loss provision. We
indicated in the November 2004 IPF PPS final rule (69 FR 66932) that we
would remove this 0.39 percent reduction to the Federal per diem base
rate after the transition. For RY 2009 and beyond, the stop-loss
[[Page 23109]]
provision has ended and is therefore no longer a part of budget
neutrality.
Due to new section 1886(s)(3)(A) of the Act, which requires the
application of an ``Other Adjustment'' that reduces the update to the
IPF PPS base rate for the rate year beginning in CY 2010, we reduced
the update to the IPF PPS base rate by 0.25 percent for rate year 2011.
Applying the market basket increase of 2.4 percent, with the ``Other
Adjustment'' of -0.25%, and the wage index budget neutrality factor of
0.9999 to the RY 2010 Federal per diem base rate of $651.76 yields a
Federal per diem base rate of $665.71 for RY 2011. Similarly, applying
the market basket increase with the ``Other Adjustment'', and the wage
index budget neutrality factor to the RY 2010 ECT rate yields an ECT
rate of $286.60 for RY 2011.
a. Market Basket Index for the IPF PPS
The market basket index that was used to develop the IPF PPS was
the excluded hospital with capital market basket. This market basket
was based on 1997 Medicare cost report data and included data for
Medicare-participating IPFs, inpatient rehabilitation facilities
(IRFs), long-term care hospitals (LTCHs), cancer, and children's
hospitals.
Beginning with the May 2006 IPF PPS final rule (71 FR 27046 through
27054), IPF PPS payments were updated using a 2002-based market basket
reflecting the operating and capital cost structures for IRFs, IPFs,
and LTCHs (hereafter referred to as the rehabilitation, psychiatric,
long-term care (RPL) market basket).
We excluded cancer and children's hospitals from the RPL market
basket because their payments are based entirely on reasonable costs
subject to rate-of-increase limits established under the authority of
section 1886(b) of the Act, which are implemented in regulations at
Sec. 413.40. They are not reimbursed through a PPS. Also, the FY 2002
cost structures for cancer and children's hospitals are noticeably
different than the cost structures of the IRFs, IPFs, and LTCHs. A
complete discussion of the RPL market basket appears in the May 2006
IPF PPS final rule (71 FR 27046 through 27054).
In the May 2009 IPF PPS notice (74 FR 20362), we requested public
comment on the possibility of creating a stand-alone IPF market basket.
In this notice, we are responding to those comments in the ``Comments
on Creating a Stand-Alone IPF Market Basket'' section.
b. Overview of the RPL Market Basket
The RPL market basket is a fixed weight, Laspeyres-type price
index. A market basket is described as a fixed-weight index because it
answers the question of how much it would cost, at another time, to
purchase the same mix (quantity and intensity) of goods and services
needed to provide services in a base period. The effects on total
expenditures resulting from changes in the mix of goods and services
purchased subsequent to the base period are not measured. In this
manner, the market basket measures pure price change only. Only when
the index is rebased would changes in the quantity and intensity be
captured in the cost weights. Therefore, we rebase the market basket
periodically so that cost weights reflect recent changes in the mix of
goods and services that hospitals purchase to furnish patient care
between base periods.
The terms ``rebasing'' and ``revising,'' while often used
interchangeably, actually denote different activities. Rebasing means
moving the base year for the structure of costs of an input price index
(for example, shifting the base year cost structure from FY 1997 to FY
2002). Revising means changing data sources, methodology, or price
proxies used in the input price index. In 2006, we rebased and revised
the market basket used to update the IPF PPS. Table 1 below sets forth
the completed FY 2002-based RPL market basket including the cost
categories, weights, and price proxies.
Table 1--FY 2002-Based RPL Market Basket Cost Categories, Weights, and
Price Proxies
------------------------------------------------------------------------
FY 2002-based
RPL market FY 2002-based RPL
Cost categories basket cost market basket price
weight proxies
------------------------------------------------------------------------
TOTAL.......................... 100.000 .......................
Compensation................... 65.877 .......................
Wages and Salaries*........ 52.895 ECI--Wages and
Salaries, Civilian
Hospital Workers.
Employee Benefits*......... 12.982 ECI--Benefits, Civilian
Hospital Workers.
Professional Fees, Non-Medical* 2.892 ECI--Compensation for
Professional & Related
occupations.
Utilities...................... 0.656 .......................
Electricity................ 0.351 PPI--Commercial
Electric Power.
Fuel Oil, Coal, etc........ 0.108 PPI--Commercial Natural
Gas.
Water and Sewage........... 0.197 CPI--U--Water & Sewage
Maintenance.
Professional Liability 1.161 CMS Professional
Insurance. Liability Premium
Index.
All Other Products and Services 19.265 .......................
All Other Products............. 13.323 .......................
Pharmaceuticals............ 5.103 PPI Prescription Drugs.
Food: Direct Purchase...... 0.873 PPI Processed Foods &
Feeds.
Food: Contract Service..... 0.620 CPI--U Food Away From
Home.
Chemicals.................. 1.100 PPI Industrial
Chemicals.
Medical Instruments........ 1.014 PPI Medical Instruments
& Equipment.
Photographic Supplies...... 0.096 PPI Photographic
Supplies.
Rubber and Plastics........ 1.052 PPI Rubber & Plastic
Products.
Paper Products............. 1.000 PPI Converted Paper &
Paperboard Products.
Apparel.................... 0.207 PPI Apparel.
Machinery and Equipment.... 0.297 PPI Machinery &
Equipment.
Miscellaneous Products**... 1.963 PPI Finished Goods less
Food & Energy.
All Other Services............. 5.942 .......................
Telephone.................. 0.240 CPI--U Telephone
Services.
Postage.................... 0.682 CPI--U Postage.
All Other: Labor Intensive* 2.219 ECI--Compensation for
Private Service
Occupations.
All Other: Non-labor 2.800 CPI--U All Items.
Intensive.
Capital-Related Costs***....... 10.149 .......................
[[Page 23110]]
Depreciation................... 6.186 .......................
Fixed Assets............... 4.250 Boeckh Institutional
Construction 23-year
useful life.
Movable Equipment.......... 1.937 PPI Machinery &
Equipment 11-year
useful life.
Interest Costs................. 2.775 .......................
Nonprofit.................. 2.081 Average yield on
domestic municipal
bonds (Bond Buyer 20
bonds) vintage-
weighted (23 years).
For Profit................. 0.694 Average yield on
Moody's Aaa bond
vintage-weighted (23
years).
Other Capital-Related Costs.... 1.187 CPI--U Residential
Rent.
------------------------------------------------------------------------
* Labor-related.
** Blood and blood-related products is included in miscellaneous
products.
*** A portion of capital costs (0.46) are labor-related.
Note: Due to rounding, weights may not sum to total.
We evaluated the price proxies using the criteria of reliability,
timeliness, availability, and relevance. Reliability indicates that the
index is based on valid statistical methods and has low sampling
variability. Timeliness implies that the proxy is published regularly
(preferably at least once a quarter). Availability means that the proxy
is publicly available. Finally, relevance means that the proxy is
applicable and representative of the cost category weight to which it
is applied. The Consumer Price Indexes (CPIs), Producer Price Indexes
(PPIs), and Employment Cost Indexes (ECIs) used as proxies in this
market basket meet these criteria.
We note that the proxies are the same as those used for the FY
1997-based excluded hospital with capital market basket. Because these
proxies meet our criteria of reliability, timeliness, availability, and
relevance, we believe they continue to be the best measure of price
changes for the cost categories. For further discussion on the FY 1997-
based excluded hospital with capital market basket, see the August 1,
2002 hospital inpatient prospective payment system (IPPS) final rule
(67 FR at 50042).
The RY 2011 (that is, beginning July 1, 2010) update for the IPF
PPS using the FY 2002-based RPL market basket and Information Handling
Services (IHS) Global Insight's 1st quarter 2010 forecast for the
market basket components is 2.4 percent. This includes increases in
both the operating section and the capital section for the 12-month RY
period (that is, July 1, 2010 through June 30, 2011). IHS Global
Insight, Inc. is a nationally recognized economic and financial
forecasting firm that contracts with CMS to forecast the components of
the market baskets.
2. Labor-Related Share
Due to the variations in costs and geographic wage levels, we
believe that payment rates under the IPF PPS should continue to be
adjusted by a geographic wage index. This wage index applies to the
labor-related portion of the Federal per diem base rate, hereafter
referred to as the labor-related share.
The labor-related share is determined by identifying the national
average proportion of operating costs that are related to, influenced
by, or vary with the local labor market. Using our current definition
of labor-related, the labor-related share is the sum of the relative
importance of wages and salaries, fringe benefits, professional fees,
labor-intensive services, and a portion of the capital share from an
appropriate market basket. We used the FY 2002-based RPL market basket
cost weights relative importance to determine the labor-related share
for the IPF PPS.
The labor-related share for RY 2011 is the sum of the RY 2011
relative importance of each labor-related cost category, and reflects
the different rates of price change for these cost categories between
the base year (FY 2002) and RY 2011. The sum of the relative importance
for the RY 2011 operating costs (wages and salaries, employee benefits,
professional fees, and labor-intensive services) is 71.506 percent, as
shown in Table 2 below. The portion of capital that is influenced by
the local labor market is estimated to be 46 percent, which is the same
percentage used in the FY 1997-based IRF and IPF payment systems.
Since the relative importance for capital is 8.466 percent of the
FY 2002-based RPL market basket in RY 2011, we are taking 46 percent of
8.466 percent to determine the labor-related share of capital for RY
2011. The result is 3.894 percent, which we added to 71.506 percent for
the operating cost amount to determine the total labor-related share
for RY 2011. Thus, the labor-related share that we are using for IPF
PPS in RY 2011 is 75.400 percent. Table 2 below shows the RY 2011
labor-related share using the FY 2002-based RPL market basket. We note
that this labor-related share is determined by using the same
methodology as employed in calculating all previous IPF labor-related
shares.
A complete discussion of the IPF labor-related share methodology
appears in the November 2004 IPF PPS final rule (69 FR 66952 through
66954).
Table 2--Total Labor-Related Share--Relative Importance for RY 2011
------------------------------------------------------------------------
FY
FY 2002-based RPL 2002[dash]based
market basket RPL market basket
labor-related labor-related
Cost category share relative share relative
importance importance
(percent) RY 2010 (percent) RY 2011
* **
------------------------------------------------------------------------
Wages and salaries................ 53.062 52.600
Employee benefits................. 13.852 13.935
Professional fees................. 2.895 2.853
[[Page 23111]]
All other labor-intensive services 2.126 2.118
-------------------------------------
Subtotal...................... 71.935 71.506
------------------------------------------------------------------------
Labor-related share of capital 3.954 3.894
costs (0.46).....................
-------------------------------------
Total......................... 75.889 75.400
------------------------------------------------------------------------
* Based on 2009 1st Quarter forecast.
** Based on 2010 1st Quarter forecast.
3. Comments on Creating a Stand-Alone IPF Market Basket
In the May 2009 IPF PPS notice (74 FR 20362), we expressed our
interest in exploring the possibility of creating a stand-alone IPF
market basket that reflects the cost structures of only IPF providers.
Of the available options, one would be to join the Medicare cost report
data from freestanding IPF providers (presently incorporated into the
RPL market basket) with data from hospital-based IPF providers. An
examination of the Medicare cost report data comparing freestanding and
hospital-based IPFs reveals considerable differences between the two
with respect to cost levels and cost structures.
In order to better understand the observed cost differences between
freestanding and hospital-based IPFs, we reviewed, in detail, several
explanatory variables such as geographic variation, case mix (including
DRG, comorbidity, and age), urban or rural status, length of stay,
teaching status, and the presence of a qualifying emergency department.
Despite this analysis, we were unable to sufficiently explain the
differences in costs between these two types of IPF providers. As a
result, we felt that further research was required and solicited public
comment on additional information that would help us to better
understand the reasons for the variations in costs and cost structures,
as reported by cost report data, between freestanding and hospital-
based IPFs (74 FR 20376).
We received several timely comments from the public on this issue.
A summary of the comments and our responses to those comments are
below.
Comment: Several commenters recommended that CMS consider creating
an IPF-specific market basket. These commenters stated that including
hospital-based IPF data in the market basket and pursuing a greater
understanding of the differences between freestanding and hospital-
based IPFs are both worthy undertakings. The commenters cited that from
2005 through 2007, the number of hospital-based IPFs has decreased by
1.4 percent while the number of freestanding IPFs has increased by 1.0
percent. The commenters expressed concern that these trends will
continue, and likely accelerate. Furthermore, the commenters stated
that in 2007, hospital-based IPFs experienced negative margins while
freestanding IPF margins were positive. Given that more than 60 percent
of IPF discharges are from hospital-based units, the commenters believe
that preserving access to care for these patients (especially those who
have coexisting physical conditions or experience a crisis and enter
the emergency department for treatment) is vital. One commenter stated
that including hospital-based IPF data in the market basket would
increase transparency and highlight the differences between
freestanding and hospital-based providers.
Response: We are actively examining the technical merits of
creating a stand-alone IPF market basket. Since publication of the May
2009 IPF PPS notice, we have been reviewing the Medicare cost report
and claims data for both hospital-based and freestanding IPFs to better
understand the differences in total Medicare costs per day. Parts of
our analysis were based on comments received by the public, which we
address in more detail below. Based on our research to date, which has
not adequately explained the cost-per-day differences between
freestanding and hospital-based providers, we do not believe it is
technically appropriate to move from the RPL market basket to update
IPF payments at this time.
Comment: Several commenters supported the ongoing application of
the RPL market basket to update inpatient psychiatric facility payment
rates. One commenter recommended we continue this method in order to
maintain a reasonable population size of facilities to ensure stability
in the calculation of the market basket. The commenter asserted that if
the RPL market basket was split into separate market baskets for IRFs,
IPFs, and LTCHs, there would be much more volatility in the year-to-
year changes, especially for LTCHs.
Response: We appreciate the comments regarding the continued
support for using the RPL market basket to update inpatient psychiatric
facility payment rates. Likewise, we appreciate the comment regarding
sample size considerations with respect to splitting the RPL market
basket into its respective pieces. Indeed, sample size and its impact
on the volatility of the estimates will be extensively scrutinized
before we would propose to change the mechanism used to update payments
to inpatient psychiatric facilities, inpatient rehabilitation
facilities, and long-term care hospitals.
Comment: One commenter supported the investigation of the
differences in cost structures between hospital-based and freestanding
IPFs. Besides determining the source of these differences, the
commenter also stated it is important for CMS to determine whether the
differences should be recognized (for example, are higher costs in IPF
hospital-based facilities due to allocation of overhead to the unit or
to differences in case mix or patient severity that is not measurable
using available administrative data). This commenter also acknowledged
that seeking outside input regarding differences in cost structures
between hospital-based and freestanding IPFs is appropriate. However,
the commenter
[[Page 23112]]
recommended that CMS proceed with caution as it may be difficult for
CMS to confirm that the methods used to collect outside data are sound
and that the data are representative of the industry as a whole. The
commenter also stated that CMS should ultimately determine whether the
market basket should in fact be based on the cost structure of
hospital-based and freestanding IPFs (instead of just one type of
facility) if the higher costs cannot be explained by differences in
case mix and other patient characteristics.
Response: Although we asked for outside information to help us
better understand these differences, we agree with the commenter that
any outside information should be carefully examined.
As we have stated, we currently do not feel it is appropriate to
incorporate data from hospital-based IPFs with that of freestanding
IPFs to create a stand-alone IPF market basket given the observed and
unexplained differences in cost structures.
Comment: Several commenters stated that creating a stand-alone IPF
market basket could be a more accurate index for the costs of
delivering care incurred by IPFs. However, the commenters stated that
they did not have any independent data to help CMS in developing a
stand-alone market basket at this time. The commenters suggested that
the issue of a stand-alone IPF market basket continue to be analyzed by
CMS.
Response: We agree with the commenters and plan to continue to
analyze costs and Medicare claims data for hospital-based and
freestanding providers.
Comment: One commenter supports the development of a stand-alone
IPF market basket. However, the commenter encourages CMS to avoid
mixing data from hospital-based and freestanding IPFs. The commenter
claims that hospital-based IPFs incur higher costs than freestanding
IPFs in treating Medicare patients for the following reasons:
The acuity levels and medical needs of psychiatric
patients that present in a hospital's qualified emergency room will
result in higher treatment costs and lengths of stay.
Hospitals provide a greater range of ancillary services.
Some hospitals operate approved psychiatric residency
teaching programs.
Therefore, the commenter is reluctant to support a combined
hospital-based, freestanding IPF market basket at this time. The
commenter also offered to assist CMS with any information he or she can
provide.
Response: We appreciate the commenter's input on possible reasons
why hospital-based IPFs have higher costs than freestanding IPFs. As
stated above, we compared the medical needs of the patients, as
measured by the adjustments for DRG, comorbidities, and age. Our
analysis did show that hospital-based providers, on average, treat more
complex patients; however, the differences in the complexity of the
patients, as well as other facility-based adjustments, did not
adequately explain the differences in total Medicare costs per day
between hospital-based and freestanding providers. In addition, using
both Medicare cost report and claims data, we found that hospital-based
providers, on average, had shorter lengths of stay than freestanding
providers.
Per the commenter's suggestion, and using MCR data, we also
compared the Medicare ancillary costs per day of hospital-based and
freestanding providers. We found that hospital-based facilities, on
average, tend to have higher Medicare ancillary costs per day than
freestanding facilities. The differences were mostly attributable to
higher emergency room and laboratory costs. These higher ancillary
costs accounted for about ten percent of the overall difference between
hospital-based and freestanding providers' total Medicare costs per
day.
In addition, we compared the average approved teaching costs for
hospital-based and freestanding providers. We found that hospital-based
providers have higher teaching-related costs associated with Medicare
approved programs relative to free standing providers; however, the
difference accounted for only three percent of the total difference in
Medicare costs per day for hospital-based and freestanding providers.
Comment: One commenter simply agreed with CMS that before
implementation of a new market basket method, the method should be
fully evaluated and the projected impact known.
Response: We agree with the commenter's suggestion. Before any
implementation, CMS will fully evaluate our methodology to ensure that
any proposed market basket most accurately reflects the cost structures
associated with providing psychiatric care to Medicare patients.
Comment: One commenter does not support the adoption of a stand-
alone IPF market basket at this time, pending further study, as the
commenter is not convinced that CMS has the appropriate level of
psychiatric cost data available to compile an accurate market basket
for IPFs alone. These conclusions were based on the following reasons:
There are a small number of facilities and often limited
data (for example, only 4 percent of IPFs reported contract labor costs
for FY 2002).
Benefits, contract labor, and blood cost weights were
developed using the FY 2002-based IPPS market basket.
Other detailed cost categories were derived from the FY
2002-based IPPS market basket.
No cost data specific to psychiatry (that is, Wages and
Salaries--based on Civilian Hospital Workers).
The commenter stated that without release of both relevant internal
data available only to CMS on the previously mentioned IPF market
basket issues, as well as specific data on the types of cost
differences between the various cost categories of IRF, IPF, and LTCH
facilities, they are unable to comment on an independent IPF market
basket at this time. The commenter believes that more detailed analysis
needs to be conducted and released before they could consider
supporting any change to the current RPL-based market basket update
process.
Response: We are in the process of evaluating multiple years of
data in order to determine whether a stand-alone IPF market basket
would be a more appropriate index for updating IPF PPS payments. We
agree with the commenter that there is a lack of IPF-specific benefit
and contract labor cost data. Currently, benefit and contract labor
cost data are collected on Worksheet S-3, part II of the Medicare cost
report (MCR), but are only required of IPPS hospitals. We proposed
under separate cover to modify the present-day hospital MCR in order to
collect benefit and contract labor data on a separate worksheet
(proposed Worksheet S-3, part V) which would be completed by all
hospitals (http://www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=descending&itemID=CMS1224069&intNumPerPage).
We disagree with the commenter that we are not capturing IPF-specific
data for wages and salaries since all hospitals are required to report
this data on the MCRs, which provides the sources of our wages and
salaries cost weight. We believe the commenter may be referencing the
Employment Cost Index (ECI) for wages and salaries for hospital
civilian workers which we use to proxy price changes associated with
the wages and salary cost weight. This proxy is used because the Bureau
of Labor
[[Page 23113]]
Statistics does not publish a wages and salaries price index specific
to IPFs only. However, the ECI for wages and salaries for hospital
civilian workers does include the price changes of IPFs, as well as
other hospital-types (including general surgical hospitals).
IV. Update of the IPF PPS Adjustment Factors
A. Overview of the IPF PPS Adjustment Factors
The IPF PPS payment adjustments were derived from a regression
analysis of 100 percent of the FY 2002 MedPAR data file, which
contained 483,038 cases. For this notice, we used the same results of
the regression analysis used to implement the November 2004 IPF PPS
final rule. For a more detailed description of the data file used for
the regression analysis, see the November 2004 IPF PPS final rule (69
FR 66935 through 66936). While we have since used more recent claims
data to set the fixed dollar loss threshold amount, we use the same
results of this regression analysis to update the IPF PPS for RY 2010
as well as RY 2011.
As previously stated, we do not plan to update the regression
analysis until we are able to analyze IPF PPS claims and cost report
data. However, we continue to monitor claims and payment data
independently from cost report data to assess issues, to determine
whether changes in case-mix or payment shifts have occurred among
freestanding governmental, non-profit and private psychiatric
hospitals, and psychiatric units of general hospitals, and CAHs and
other issues of importance to IPFs.
B. Patient-Level Adjustments
In the May 2008 IPF PPS notice (73 FR 25709) and in the May 2009
IPF PPS notice (74 FR 20362), we provided payment adjustments for the
following patient-level characteristics: Medicare Severity diagnosis
related groups (MS-DRGs) assignment of the patient's principal
diagnosis, selected comorbidities, patient age, and the variable per
diem adjustments.
1. Adjustment for MS-DRG Assignment
The IPF PPS includes payment adjustments for the psychiatric DRG
assigned to the claim based on each patient's principal diagnosis. The
IPF PPS recognizes the MS-DRGs. The DRG adjustment factors were
expressed relative to the most frequently reported psychiatric DRG in
FY 2002, that is, DRG 430 (psychoses). The coefficient values and
adjustment factors were derived from the regression analysis.
In accordance with Sec. 412.27(a), payment under the IPF PPS is
conditioned on IPFs admitting ``only patients whose admission to the
unit is required for active treatment, of an intensity that can be
provided appropriately only in an inpatient hospital setting, of a
psychiatric principal diagnosis that is listed in Chapter Five
(``Mental Disorders'') of the International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM)'' or in the Fourth
Edition, Text Revision of the American Psychiatric Association's
Diagnostic and Statistical Manual, (DSM-IV-TR). IPF claims with a
principal diagnosis included in Chapter Five of the ICD-9-CM or the
DSM-IV-TR are paid the Federal per diem base rate under the IPF PPS and
all other applicable adjustments, including any applicable DRG
adjustment. Psychiatric principal diagnoses that do not group to one of
the designated DRGs still receive the Federal per diem base rate and
all other applicable adjustments, but the payment would not include a
DRG adjustment.
The Standards for Electronic Transaction final rule published in
the Federal Register on August 17, 2000 (65 FR 50312), adopted the ICD-
9-CM as the designated code set for reporting diseases, injuries,
impairments, other health related problems, their manifestations, and
causes of injury, disease, impairment, or other health related
problems. Therefore, we use the ICD-9-CM as the designated code set for
the IPF PPS.
We believe that it is important to maintain the same diagnostic
coding and DRG classification for IPFs that are used under the IPPS for
providing the psychiatric care. Therefore, when the IPF PPS was
implemented for cost reporting periods beginning on or after January 1,
2005, we adopted the same diagnostic code set and DRG patient
classification system (that is, the CMS DRGs) that was utilized at the
time under the hospital inpatient prospective payment system (IPPS).
Since the inception of the IPF PPS, the DRGs used as the patient
classification system under the IPF PPS have corresponded exactly with
the CMS DRGs applicable under the IPPS for acute care hospitals.
Every year, changes to the ICD-9-CM coding system are addressed in
the IPPS proposed and final rules. The changes to the codes are
effective October 1 of each year and must be used by acute care
hospitals as well as other providers to report diagnostic and procedure
information. The IPF PPS has always incorporated ICD-9-CM coding
changes made in the annual IPPS update. We publish coding changes in a
Transmittal/Change Request, similar to how coding changes are announced
by the IPPS and LTCH PPS. Those ICD-9-CM coding changes are also
published in the following IPF PPS RY update, in either the IPF PPS
proposed and final rules, or in an IPF PPS update notice.
In the May 2008 IPF PPS notice (73 FR 25714), we discussed CMS'
effort to better recognize resource use and the severity of illness
among patients. CMS adopted the new MS-DRGs for the IPPS in the FY 2008
IPPS final rule with comment period (72 FR 47130). We believe by better
accounting for patients' severity of illness in Medicare payment rates,
the MS-DRGs encourage hospitals to improve their coding and
documentation of patient diagnoses. The MS-DRGs, which are based on the
CMS DRGs, represent a significant increase in the number of DRGs (from
538 to 745, an increase of 207). For a full description of the
development and implementation of the MS-DRGs, see the FY 2008 IPPS
final rule with comment period (72 FR 47141 through 47175).
All of the ICD-9-CM coding changes are reflected in the FY 2010
GROUPER, Version 27.0, effective for IPPS discharges occurring on or
after October 1, 2009 through September 30, 2010. The GROUPER Version
27.0 software package assigns each case to an MS-DRG on the basis of
the diagnosis and procedure codes and demographic information (that is,
age, sex, and discharge status). The Medicare Code Editor (MCE) 26.0
uses the new ICD-9-CM codes to validate coding for IPPS discharges on
or after October 1, 2009. For additional information on the GROUPER
Version 27.0 and MCE 26.0, see Transmittal 1816 (Change Request 6634),
dated October 1, 2009. The IPF PPS has always used the same GROUPER and
Code Editor as the IPPS. Therefore, the ICD-9-CM changes, which were
reflected in the GROUPER Version 27.0 and MCE 26.0 on October 1, 2009,
also became effective for the IPF PPS for discharges occurring on or
after October 1, 2009.
The impact of the new MS-DRGs on the IPF PPS was negligible.
Mapping to the MS-DRGs resulted in the current 17 MS-DRGs, instead of
the original 15 DRGs, for which the IPF PPS provides an adjustment.
Although the code set is updated, the same associated adjustment
factors apply now that have been in place since implementation of the
IPF PPS, with one exception that is unrelated to the update to the
codes. When DRGs 521 and 522 were consolidated into MS-DRG 895, we
carried over the adjustment factor of 1.02 from DRG 521 to the newly
[[Page 23114]]
consolidated MS-DRG. This was done to reflect the higher claims volume
under DRG 521, with more than eight times the number of claims than
billed under DRG 522. The updates are reflected in Table 5. For a
detailed description of the mapping changes from the original DRG
adjustment categories to the current MS-DRG adjustment categories, we
refer readers to the May 2008 IPF PPS notice (73 FR 25714).
The official version of the ICD-9-CM is available on CD-ROM from
the U.S. Government Printing Office. The FY 2009 version can be ordered
by contacting the Superintendent of Documents, U.S. Government Printing
Office, Department 50, Washington, DC 20402-9329, telephone number
(202) 512-1800. Questions concerning the ICD-9-CM should be directed to
Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and
Maintenance Committee, CMS, Center for Medicare Management, Hospital
and Ambulatory Policy Group, Division of Acute Care, Mailstop C4-08-06,
7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Further information concerning the official version of the ICD-9-CM
can be found in the IPPS final rule with comment period, ``Changes to
Hospital Inpatient Prospective Payment System and Fiscal Year 2010
Rates'' in the August 27, 2009 Federal Register (74 FR 43754) and at
http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/list.asp#TopOfPage.
Tables 3 and 4 below list the FY 2010 new and invalid ICD-9-CM
diagnosis codes that group to one of the 17 MS-DRGs for which the IPF
PPS provides an adjustment. These tables are only a listing of FY 2010
changes and do not reflect all of the currently valid and applicable
ICD-9-CM codes classified in the MS-DRGs. When coded as a principal
code or diagnosis, these codes receive the correlating MS-DRG
adjustment.
Table 3--FY 2010 New Diagnosis Codes
------------------------------------------------------------------------
Diagnosis code Description MS-DRG
------------------------------------------------------------------------
438.13..................... Late effects of 056, 057
cerebrovascular disease,
dysarthria.
438.14..................... Late effects of 056, 057
cerebrovascular disease,
fluency disorder.
799.21..................... Nervousness................ 880
799.22..................... Irritability............... 880
799.23..................... Impulsiveness.............. 882
799.24..................... Emotional lability......... 883
799.25..................... Demoralization and apathy.. 880
799.29..................... Other signs and symptoms 880
involving emotional state.
------------------------------------------------------------------------
Table 4--FY 2010 Invalid Diagnosis Codes
------------------------------------------------------------------------
Diagnosis code Description MS-DRG
------------------------------------------------------------------------
799.2....................... Nervousness................... 880
------------------------------------------------------------------------
We do not plan to update the regression analysis until we are able
to analyze IPF PPS data. The MS-DRG adjustment factors (as shown in
Table 5 below) will continue to be paid for discharges occurring in RY
2011.
Table 5--RY 2011 Current MS-DRGs Applicable for the Principal Diagnosis
Adjustment
------------------------------------------------------------------------
Adjustment
MS-DRG MS-DRG descriptions factor
------------------------------------------------------------------------
056........................ Degenerative nervous system 1.05
disorders w MCC.
057........................ Degenerative nervous system 1.05
disorders w/o MCC.
080........................ Nontraumatic stupor & coma 1.07
w MCC.
081........................ Nontraumatic stupor & coma 1.07
w/o MCC.
876........................ O.R. procedure w principal 1.22
diagnoses of mental
illness.
880........................ Acute adjustment reaction & 1.05
psychosocial dysfunction.
881........................ Depressive neuroses........ 0.99
882........................ Neuroses except depressive. 1.02
883........................ Disorders of personality & 1.02
impulse control.
884........................ Organic disturbances & 1.03
mental retardation.
885........................ Psychoses.................. 1.00
886........................ Behavioral & developmental 0.99
disorders.
887........................ Other mental disorder 0.92
diagnoses.
894........................ Alcohol/drug abuse or 0.97
dependence, left AMA.
895........................ Alcohol/drug abuse or 1.02
dependence w
rehabilitation therapy.
896........................ Alcohol/drug abuse or 0.88
dependence w/o
rehabilitation therapy w
MCC.
897........................ Alcohol/drug abuse or 0.88
dependence w/o
rehabilitation therapy w/o
MCC.
------------------------------------------------------------------------
2. Payment for Comorbid Conditions
The intent of the comorbidity adjustments is to recognize the
increased costs associated with comorbid conditions by providing
additional payments for certain concurrent medical or psychiatric
conditions that are expensive to treat. In the May 2009 IPF PPS notice
(74 FR 20362), we explained that the IPF PPS includes 17 comorbidity
categories and identified the new, revised, and deleted ICD-9-CM
diagnosis codes that generate a comorbid condition payment adjustment
under the IPF PPS for RY 2010 (77 FR 20372).
Comorbidities are specific patient conditions that are secondary to
the patient's principal diagnosis and that require treatment during the
stay.
[[Page 23115]]
Diagnoses that relate to an earlier episode of care and have no bearing
on the current hospital stay are excluded and must not be reported on
IPF claims. Comorbid conditions must exist at the time of admission or
develop subsequently, and affect the treatment received, length of stay
(LOS), or both treatment and LOS.
For each claim, an IPF may receive only one comorbidity adjustment
per comorbidity category, but it may receive an adjustment for more
than one comorbidity category. Billing instructions require that IPFs
must enter the full ICD-9-CM codes for up to 8 additional diagnoses if
they co-exist at the time of admission or develop subsequently and
impact the treatment provided.
The comorbidity adjustments were determined based on the regression
analysis using the diagnoses reported by IPFs in FY 2002. The principal
diagnoses were used to establish the DRG adjustments and were not
accounted for in establishing the comorbidity category adjustments,
except where ICD-9-CM ``code first'' instructions apply. As we
explained in the May 2008 IPF PPS notice (73 FR 25716), the code first
rule applies when a condition has both an underlying etiology and a
manifestation due to the underlying etiology. For these conditions, the
ICD-9-CM has a coding convention that requires the underlying
conditions to be sequenced first followed by the manifestation.
Whenever a combination exists, there is a ``use additional code'' note
at the etiology code and a code first note at the manifestation code.
As discussed in the MS-DRG section, it is our policy to maintain
the same diagnostic coding set for IPFs that is used under the IPPS for
providing the same psychiatric care. Although the ICD-9-CM code set has
been updated, the same adjustment factors have been in place since the
implementation of the IPF PPS. Table 6 below lists the FY 2010 new ICD
diagnosis codes that impact the comorbidity adjustments under the IPF
PPS. Table 6 is not a list of all currently valid ICD codes applicable
for the IPF PPS comorbidity adjustments.
Table 6--FY 2010 New ICD Codes Applicable for the Comorbidity Adjustment
------------------------------------------------------------------------
Diagnosis code Description Comorbidity category
------------------------------------------------------------------------
209.31............... Merkel cell Oncology Treatment.
carcinoma of
the face.
209.32............... Merkel cell Oncology Treatment.
carcinoma of
the scalp and
neck.
209.33............... Merkel cell Oncology Treatment.
carcinoma of
the upper limb.
209.34............... Merkel cell Oncology Treatment.
carcinoma of
the lower limb.
209.35............... Merkel cell Oncology Treatment.
carcinoma of
the trunk.
209.36............... Merkel cell Oncology Treatment.
carcinoma of
other sites.
209.70............... Secondary Oncology Treatment.
neuroendocrine
tumor,
unspecified
site.
209.71............... Secondary Oncology Treatment.
neuroendocrine
tumor of
distant lymph
nodes.
209.72............... Secondary Oncology Treatment.
neuroendocrine
tumor of liver.
209.73............... Secondary Oncology Treatment.
neuroendocrine
tumor of bone.
209.74............... Secondary Oncology Treatment.
neuroendocrine
tumor of
peritoneum.
209.75............... Secondary Merkel Oncology Treatment.
cell carcinoma.
209.79............... Secondary Oncology Treatment.
neuroendocrine
tumor of other
sites.
239.81............... Neoplasms of Oncology Treatment.
unspecified
nature, retina
and choroid.
239.89............... Neoplasms of Oncology Treatment.
unspecified
nature, other
specified sites.
969.00............... Poisoning by Poisoning.
antidepressant,
unspecified.
969.01............... Poisoning by Poisoning.
monoamine
oxidase
inhibitors.
969.02............... Poisoning by Poisoning.
selective
serotonin and
norepinephrine
reuptake
inhibitors.
969.03............... Poisoning by Poisoning.
selective
serotonin
reuptake
inhibitors.
969.04............... Poisoning by Poisoning.
tetracyclic
antidepressants.
969.05............... Poisoning by Poisoning.
tricyclic
antidepressants.
969.09............... Poisoning by Poisoning.
other
antidepressants.
969.70............... Poisoning by Poisoning.
psychostimulant
, unspecified.
969.71............... Poisoning by Poisoning.
caffeine.
969.72............... Poisoning by Poisoning.
amphetamines.
969.73............... Poisoning by Poisoning.
methylphenidate.
969.79............... Poisoning by Poisoning.
other
psychostimulant
s.
------------------------------------------------------------------------
Table 7 below lists the FY 2010 revised ICD diagnosis codes that
are applicable for the comorbidity adjustment.
Table 7--FY 2010 Revised ICD Codes Applicable for the Comorbidity
Adjustment
------------------------------------------------------------------------
Diagnosis code Description Comorbidity category
------------------------------------------------------------------------
584.5................ Acute kidney Renal Failure, Acute.
failure with
lesion of
tubular
necrosis.
584.6................ Acute kidney Renal Failure, Acute.
failure with
lesion of renal
cortical
necrosis.
584.7................ Acute kidney Renal Failure, Acute.
failure with
lesion of renal
medullary
[papillary]
necrosis.
584.8................ Acute kidney Renal Failure, Acute.
failure with
other specified
pathological
lesion in
kidney.
584.9................ Acute kidney Renal Failure, Acute.
failure,
unspecified.
639.3................ Kidney failure Renal Failure, Acute.
following
abortion and
ectopic and
molar
pregnancies.
669.32............... Acute kidney Renal Failure, Acute.
failure
following labor
and delivery,
delivered, with
mention of
postpartum
complication.
669.34............... Acute kidney Renal Failure, Acute.
failure
following labor
and delivery,
postpartum
condition or
complication.
------------------------------------------------------------------------
[[Page 23116]]
Table 8 below lists the invalid FY 2010 ICD-9-CM codes no longer
applicable for the comorbidity adjustment.
Table 8--FY 2010 Invalid ICD Codes No Longer Applicable for the
Comorbidity Adjustment
------------------------------------------------------------------------
Diagnosis code Description Comorbidity category
------------------------------------------------------------------------
239.8................ Neoplasm of Oncology Treatment.
unspecified
nature of other
specified sites.
969.0................ Poisoning by Poisoning.
antidepressants.
969.7................ Poisoning by Poisoning.
psychostimulant
s.
------------------------------------------------------------------------
For RY 2011, we are applying the seventeen comorbidity categories
for which we are providing an adjustment, their respective codes,
including the new FY 2010 ICD-9-CM codes, and their respective
adjustment factors in Table 9 below.
Table 9--RY 2011 Diagnosis Codes and Adjustment Factors for Comorbidity
Categories
------------------------------------------------------------------------
Adjustment
Description of comorbidity ICD-9CM code factor
------------------------------------------------------------------------
Developmental Disabilities..... 317, 3180, 3181, 3182, 1.04
and 319.
Coagulation Factor Deficits.... 2860 through 2864...... 1.13
Tracheostomy................... 51900 through 51909 and 1.06
V440.
Renal Failure, Acute........... 5845 through 5849, 1.11
63630, 63631, 63632,
63730, 63731, 63732,
6383, 6393, 66932,
66934, 9585.
Renal Failure, Chronic......... 40301, 40311, 40391, 1.11
40402, 40412, 40413,
40492, 40493, 5853,
5854, 5855, 5856,
5859, 586, V4511,
V4512, V560, V561, and
V562.
Oncology Treatment............. 1400 through 2399 with 1.07
a radiation therapy
code 92.21-92.29 or
chemotherapy code
99.25.
Uncontrolled Diabetes-Mellitus 25002, 25003, 25012, 1.05
with or without complications. 25013, 25022, 25023,
25032, 25033, 25042,
25043, 25052, 25053,
25062, 25063, 25072,
25073, 25082, 25083,
25092, and 25093.
Severe Protein Calorie 260 through 262........ 1.13
Malnutrition.
Eating and Conduct Disorders... 3071, 30750, 31203, 1.12
31233, and 31234.
Infectious Disease............. 01000 through 04110, 1.07
042, 04500 through
05319, 05440 through
05449, 0550 through
0770, 0782 through
07889, and 07950
through 07959.
Drug and/or Alcohol Induced 2910, 2920, 29212, 1.03
Mental Disorders. 2922, 30300, and 30400.
Cardiac Conditions............. 3910, 3911, 3912, 1.11
40201, 40403, 4160,
4210, 4211, and 4219.
Gangrene....................... 44024 and 7854......... 1.10
Chronic Obstructive Pulmonary 49121, 4941, 5100, 1.12
Disease. 51883, 51884, V4611,
V4612, V4613 and V4614.
Artificial Openings--Digestive 56960 through 56969, 1.08
and Urinary. 9975, and V441 through
V446.
Severe Musculoskeletal and 6960, 7100, 73000 1.09
Connective Tissue Diseases. through 73009, 73010
through 73019, and
73020 through 73029.
Poisoning...................... 96500 through 96509, 1.11
9654, 9670 through
9699, 9770, 9800
through 9809, 9830
through 9839, 986,
9890 through 9897.
------------------------------------------------------------------------
3. Patient Age Adjustments
As explained in the November 2004 IPF PPS final rule (69 FR 66922),
we analyzed the impact of age on per diem cost by examining the age
variable (that is, the range of ages) for payment adjustments.
In general, we found that the cost per day increases with age. The
older age groups are more costly than the under 45 age group, the
differences in per diem cost increase for each successive age group,
and the differences are statistically significant.
For RY 2011, we are continuing to use the patient age adjustments
currently in effect as shown in Table 10 below.
Table 10--Age Groupings and Adjustment Factors
------------------------------------------------------------------------
Adjustment
Age factor
------------------------------------------------------------------------
Under 45.................................................. 1.00
45 and under 50........................................... 1.01
50 and under 55........................................... 1.02
55 and under 60........................................... 1.04
60 and under 65........................................... 1.07
65 and under 70........................................... 1.10
70 and under 75........................................... 1.13
75 and under 80........................................... 1.15
80 and over............................................... 1.17
------------------------------------------------------------------------
4. Variable Per Diem Adjustments
We explained in the November 2004 IPF PPS final rule (69 FR 66946)
that the regression analysis indicated that per diem cost declines as
the LOS increases. The variable per diem adjustments to the Federal per
diem base rate account for ancillary and administrative costs that
occur disproportionately in the first days after admission to an IPF.
We used a regression analysis to estimate the average differences
in per diem cost among stays of different lengths. As a result of this
analysis, we established variable per diem adjustments that begin on
day 1 and decline gradually until day 21 of a patient's stay. For day
22 and thereafter, the variable per diem adjustment remains the same
each day for the remainder of the stay. However, the adjustment applied
to day 1 depends upon whether the IPF has a qualifying ED. If an IPF
has a qualifying ED, it receives a 1.31 adjustment factor for day 1 of
each stay. If an IPF does not have a qualifying ED, it receives a 1.19
adjustment factor for day 1 of the stay. The ED adjustment is explained
in more detail in section IV.C.5 of this notice.
[[Page 23117]]
For RY 2011, we are continuing to use the variable per diem
adjustment factors currently in effect as shown in Table 11 below. A
complete discussion of the variable per diem adjustments appears in the
November 2004 IPF PPS final rule (69 FR 66946).
Table 11--Variable Per Diem Adjustments
------------------------------------------------------------------------
Adjustment
Day-of-stay factor
------------------------------------------------------------------------
Day 1--IPF Without a Qualifying ED........................ 1.19
Day 1--IPF With a Qualifying ED........................... 1.31
Day 2..................................................... 1.12
Day 3..................................................... 1.08
Day 4..................................................... 1.05
Day 5..................................................... 1.04
Day 6..................................................... 1.02
Day 7..................................................... 1.01
Day 8..................................................... 1.01
Day 9..................................................... 1.00
Day 10.................................................... 1.00
Day 11.................................................... 0.99
Day 12.................................................... 0.99
Day 13.................................................... 0.99
Day 14.................................................... 0.99
Day 15.................................................... 0.98
Day 16.................................................... 0.97
Day 17.................................................... 0.97
Day 18.................................................... 0.96
Day 19.................................................... 0.95
Day 20.................................................... 0.95
Day 21.................................................... 0.95
After Day 21.............................................. 0.92
------------------------------------------------------------------------
C. Facility-Level Adjustments
The IPF PPS includes facility-level adjustments for the wage index,
IPFs located in rural areas, teaching IPFs, cost of living adjustments
for IPFs located in Alaska and Hawaii, and IPFs with a qualifying ED.
1. Wage Index Adjustment
a. Background
As discussed in the May 2006 IPF PPS final rule and in the May 2008
and May 2009 update notices, in providing an adjustment for geographic
wage levels, the labor-related portion of an IPF's payment is adjusted
using an appropriate wage index. Currently, an IPF's geographic wage
index value is determined based on the actual location of the IPF in an
urban or rural area as defined in Sec. 412.64(b)(1)(ii)(A) through
Sec. 412.64(C).
b. Wage Index for RY 2011
Since the inception of the IPF PPS, we have used hospital wage data
in developing a wage index to be applied to IPFs. We are continuing
that practice for RY 2011. We apply the wage index adjustment to the
labor-related portion of the Federal rate, which is 75.400 percent.
This percentage reflects the labor-related relative importance of the
RPL market basket for RY 2011 (see section III.B.2 of this notice). The
IPF PPS uses the pre-floor, pre-reclassified hospital wage index.
Changes to the wage index are made in a budget neutral manner so that
updates do not increase expenditures.
For RY 2011, we are applying the most recent hospital wage index
(that is, the FY 2010 pre-floor, pre-reclassified hospital wage index
because this is the most appropriate index as it best reflects the
variation in local labor costs of IPFs in the various geographic areas)
using the most recent hospital wage data (that is, data from hospital
cost reports for the cost reporting period beginning during FY 2006),
and applying an adjustment in accordance with our budget neutrality
policy. This policy requires us to estimate the total amount of IPF PPS
payments in RY 2010 using the applicable wage index value divided by
the total estimated IPF PPS payments in RY 2011 using the most recent
wage index. The estimated payments are based on FY 2008 IPF claims,
inflated to the appropriate RY. This quotient is the wage index budget
neutrality factor, and it is applied in the update of the Federal per
diem base rate for RY 2011 in addition to the market basket described
in section III.B.1 of this notice. The wage index budget neutrality
factor for RY 2011 is 0.9999.
The wage index applicable for RY 2011 appears in Table 1 and Table
2 in Addendum B of this notice. As explained in the May 2006 IPF PPS
final rule for RY 2007 (71 FR 27061), the IPF PPS applies the hospital
wage index without a hold-harmless policy, and without an out-commuting
adjustment or out-migration adjustment because the statutory authority
for these policies applies only to the IPPS.
Also in the May 2006 IPF PPS final rule for RY 2007 (71 FR 27061),
we adopted the changes discussed in the Office of Management and Budget
(OMB) Bulletin No. 03-04 (June 6, 2003), which announced revised
definitions for Metropolitan Statistical Areas (MSAs), and the creation
of Micropolitan Statistical Areas and Combined Statistical Areas. In
adopting the OMB Core-Based Statistical Area (CBSA) geographic
designations, since the IPF PPS was already in a transition period from
TEFRA payments to PPS payments, we did not provide a separate
transition for the CBSA-based wage index.
As was the case in RY 2010, for RY 2011 we will continue to use the
CBSA-based wage index values as presented in Tables 1 and 2 in Addendum
B of this notice. A complete discussion of the CBSA labor market
definitions appears in the May 2006 IPF PPS final rule (71 FR 27061
through 27067).
In summary, for RY 2011 we will use the FY 2010 wage index data
(collected from cost reports submitted by hospitals for cost reporting
periods beginning during FY 2006) to adjust IPF PPS payments beginning
July 1,2010.
c. OMB Bulletins
The Office of Management and Budget (OMB) publishes bulletins
regarding CBSA changes, including changes to CBSA numbers and titles.
In the May 2008 IPF PPS notice, we incorporated the CBSA nomenclature
changes published in the most recent OMB bulletin that applies to the
hospital wage data used to determine the current IPF PPS wage index (73
FR 25721). We will continue to do the same for all such OMB CBSA
nomenclature changes in future IPF PPS rules and notices, as necessary.
The OMB bulletins may be accessed online at http://www.whitehouse.gov/omb/bulletins/index.html.
2. Adjustment for Rural Location
In the November 2004 IPF PPS final rule, we provided a 17 percent
payment adjustment for IPFs located in a rural area. This adjustment
was based on the regression analysis, which indicated that the per diem
cost of rural facilities was 17 percent higher than that of urban
facilities after accounting for the influence of the other variables
included in the regression. For RY 2011, we are applying a 17 percent
payment adjustment for IPFs located in a rural area as defined at Sec.
412.64(b)(1)(ii)(C). As stated in the November 2004 IPF PPS final rule,
we do not intend to update the adjustment factors derived from the
regression analysis until we are able to analyze IPF PPS data. A
complete discussion of the adjustment for rural locations appears in
the November 2004 IPF PPS final rule (69 FR 66954).
3. Teaching Adjustment
In the November 2004 IPF PPS final rule, we implemented regulations
at Sec. 412.424(d)(1)(iii) to establish a facility-level adjustment
for IPFs that are, or are part of, teaching hospitals. The teaching
adjustment accounts for the higher indirect operating costs experienced
by hospitals that participate in graduate medical education (GME)
programs. The payment adjustments are made based on the number of full-
time equivalent (FTE) interns and residents training in the IPF and the
IPF's average daily census.
Medicare makes direct GME payments (for direct costs such as
resident and
[[Page 23118]]
teaching physician salaries, and other direct teaching costs) to all
teaching hospitals including those paid under the IPPS, and those that
were once paid under the TEFRA rate-of-increase limits but are now paid
under other PPSs. These direct GME payments are made separately from
payments for hospital operating costs and are not part of the PPSs. The
direct GME payments do not address the estimated higher indirect
operating costs teaching hospitals may face.
For teaching hospitals paid under the TEFRA rate-of-increase
limits, Medicare did not make separate payments for indirect medical
education costs because payments to these hospitals were based on the
hospitals' reasonable costs which already included these higher
indirect costs that may be associated with teaching programs.
The results of the regression analysis of FY 2002 IPF data
established the basis for the payment adjustments included in the
November 2004 IPF PPS final rule. The results showed that the indirect
teaching cost variable is significant in explaining the higher costs of
IPFs that have teaching programs. We calculated the teaching adjustment
based on the IPF's ``teaching variable,'' which is one plus the ratio
of the number of FTE residents training in the IPF (subject to
limitations described below) to the IPF's average daily census (ADC).
We established the teaching adjustment in a manner that limited the
incentives for IPFs to add FTE residents for the purpose of increasing
their teaching adjustment. We imposed a cap on the number of FTE
residents that may be counted for purposes of calculating the teaching
adjustment. We emphasize that the cap limits the number of FTE
residents that teaching IPFs may count for the purposes of calculating
the IPF PPS teaching adjustment, not the number of residents teaching
institutions can hire or train. We calculated the number of FTE
residents that trained in the IPF during a ``base year'' and used that
FTE resident number as the cap. An IPF's FTE resident cap is ultimately
determined based on the final settlement of the IPF's most recent cost
report filed before November 15, 2004 (that is, the publication date of
the IPF PPS final rule).
In the regression analysis, the logarithm of the teaching variable
had a coefficient value of 0.5150. We converted this cost effect to a
teaching payment adjustment by treating the regression coefficient as
an exponent and raising the teaching variable to a power equal to the
coefficient value. We note that the coefficient value of 0.5150 was
based on the regression analysis holding all other components of the
payment system constant.
As with other adjustment factors derived through the regression
analysis, we do not plan to rerun the regression analysis until we
analyze IPF PPS data. Therefore, for RY 2011, we are retaining the
coefficient value of 0.5150 for the teaching adjustment to the Federal
per diem base rate.
A complete discussion of how the teaching adjustment was calculated
appears in the November 2004 IPF PPS final rule (69 FR 66954 through
66957) and the May 2008 IPF PPS notice (73 FR 25721).
FTE Intern and Resident Cap Adjustment
CMS has been asked to reconsider the current policy on the FTE
intern and resident cap adjustment and to permit an increase in the FTE
resident cap when the IPF increases the number of FTE residents it
trains due to the acceptance of relocated residents when another IPF
closes or closes its psychiatry residency program. To help us assess
how many IPFs have been, or expect to be adversely affected by their
inability to adjust their caps under Sec. 412.424(d)(1) and under
these situations, we specifically requested public comment from IPFs in
the May 2009 IPF PPS notice (74 FR 20362). A summary of the comments
and our response to those comments are below.
Comment: We received several comments on the FTE Intern and
Resident Cap Adjustment. All of the commenters recommended that CMS
modify the IPF PPS resident cap policy, supporting a policy change that
would permit the IPF PPS residency cap to be increased when residents
in a psychiatry residency program must be relocated from one IPF to
another due to closure of an IPF or an IPF's psychiatry residency
training program. Many commenters expressed concern that a cap on the
number of FTE residents used to calculate the teaching adjustment is
based on a snapshot of activity essentially ``freezing'' the status of
residency education at a random point in time, CY 2004. Commenters
stated that it is time to substantially modify the resident cap policy
for the IPF PPS. Several commenters stated that this change in
residency policy could help address the psychiatrist shortage, and help
ensure access to care for beneficiaries who suffer from mental health
and substance use disorders. Other commenters pointed out that the
demand for health care services will continue to rise with the growing
needs of the 78 million ``baby boomers'' who will retire in 2010 and
with the recent passage of Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equality Act of 2008. The commenters
further stated that the U.S. already faces a shortage of psychiatrists,
and these factors could potentially elevate what is now a problem to
what could be a crisis.
Several commenters stated that in FY 2000, CMS instituted a
temporary adjustment to the IPPS FTE cap policy when a hospital
increases the number of FTE residents it trains due to the acceptance
of relocated residents when another hospital closes (64 FR 41552). The
commenters further stated that in FY 2002, CMS also implemented a
similar policy for acute care hospitals that accept relocated residents
from a closed program (66 FR 39899). The commenters indicated that the
same need exists for IPFs that accept displaced residents when an IPF
closes or when an IPF or acute care hospital closes its psychiatric
residency program. The commenters recommended that CMS implement a
temporary resident cap increase policy to the current FTE resident cap
when an IPF increases the number of FTE residents it trains due to the
acceptance of relocated residents. The commenters believe this change
is necessary in order to promote consistency among payment systems and
to ensure that residents training in psychiatry can continue their
training when their original residency training program closes.
Several commenters suggested that although the extent of the
problem of displaced psychiatry residents is not clear at this time,
the number of inpatient psychiatric units is declining. Therefore, they
agreed that a temporary increase in the resident cap, similar to that
allowed for acute care hospitals, would provide an incentive for IPFs
to accept those psychiatry residents who are displaced by the closure
of residency training programs. Some commenters expressed concern that
inpatient psychiatric programs are closing in different parts of the
country and believe the cap issue could become more of a problem in the
future.
One association surveyed IPFs and concluded that the cap does
impact IPF training of psychiatric residents. Specifically, they stated
that certain IPFs reported that they trained additional residents from
a closed residency program and have exceeded their caps because of
those residents. Other IPFs in the survey reported that they had been
asked to train additional residents but had not agreed because
[[Page 23119]]
these additional residents would have caused them to exceed their cap.
Another commenter believes the cap limits the flexibility of health
systems to become more efficient by consolidating programs and
residency training. This commenter indicated that while they have not
heard of many facilities that have experienced a problem exceeding the
cap, they were aware of specific cases where it has created problems
and prevented some changes in the training of residents from one IPF to
another. The example cited was a facility in the northwest that is part
of a large health system, wanted to close down their training program
in their outpatient department and shift the residents to an IPF owned
by the health system. However, they indicated that the cap prevented
the system from moving the residents from the outpatient program to the
IPF.
Another commenter believes this change is necessary and has
personally encountered this situation when a local IPF was closed and
their residents had to be relocated, some of which came to the
commenter's facility. The commenter stated that a change in this policy
would help keep needed residency slots in the local communities.
One commenter indicated that they trained 24.56 FTE(s), which
included 1.60 FTE(s) from a closed IPF. The commenter's cap is 18.18.
The commenter indicated training of the closed IPF's residents did not
give them relief from the cap.
Response: We appreciate all comments received on the FTE intern and
resident cap adjustment. We will take all comments into consideration
as we assess the IPF PPS regulations with respect to developing the
policy for the teaching cap adjustment in the future.
4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii
The IPF PPS includes a payment adjustment for IPFs located in
Alaska and Hawaii based upon the county in which the IPF is located. As
we explained in the November 2004 IPF PPS final rule, the FY 2002 data
demonstrated that IPFs in Alaska and Hawaii had per diem costs that
were disproportionately higher than other IPFs. Other Medicare PPSs
(for example, the IPPS and LTCH PPS) have adopted a cost of living
adjustment (COLA) to account for the cost differential of care
furnished in Alaska and Hawaii.
We analyzed the effect of applying a COLA to payments for IPFs
located in Alaska and Hawaii. The results of our analysis demonstrated
that a COLA for IPFs located in Alaska and Hawaii would improve payment
equity for these facilities. As a result of this analysis, we provided
a COLA in the November 2004 IPF PPS final rule.
A COLA adjustment for IPFs located in Alaska and Hawaii is made by
multiplying the non-labor share of the Federal per diem base rate by
the applicable COLA factor based on the COLA area in which the IPF is
located.
As previously stated in the November 2004 IPF PPS final rule, we
will update the COLA factors according to updates established by the
U.S. Office of Personnel Management (OPM), which issued a final rule,
May 28, 2008 to change COLA rates.
The COLA factors are published on the OPM Web site at (http://www.opm.gov/oca/cola/rates.asp).
We note that the COLA areas for Alaska are not defined by county as
are the COLA areas for Hawaii. In 5 CFR 591.207, the OPM established
the following COLA areas:
(a) City of Anchorage, and 80-kilometer (50-mile) radius by road,
as measured from the Federal courthouse;
(b) City of Fairbanks, and 80-kilometer (50-mile) radius by road,
as measured from the Federal courthouse;
(c) City of Juneau, and 80-kilometer (50-mile) radius by road, as
measured from the Federal courthouse;
(d) Rest of the State of Alaska.
For RY 2011, IPFs located in Alaska and Hawaii will continue to
receive the updated COLA factors based on the COLA area in which the
IPF is located as shown in Table 12 below.
Table 12--COLA Factors for Alaska and Hawaii IPFs
------------------------------------------------------------------------
Location COLA
------------------------------------------------------------------------
Alaska:
Anchorage.................................................... 1.23
Fairbanks.................................................... 1.23
Juneau....................................................... 1.23
Rest of Alaska............................................... 1.25
Hawaii:
Honolulu County.............................................. 1.25
Hawaii County................................................ 1.18
Kauai County................................................. 1.25
Maui County.................................................. 1.25
Kalawao County............................................... 1.25
------------------------------------------------------------------------
5. Adjustment for IPFs With a Qualifying Emergency Department (ED)
Currently, the IPF PPS includes a facility-level adjustment for
IPFs with qualifying EDs. We provide an adjustment to the Federal per
diem base rate to account for the costs associated with maintaining a
full-service ED. The adjustment is intended to account for ED costs
incurred by a freestanding psychiatric hospital with a qualifying ED or
a distinct part psychiatric unit of an acute hospital or a CAH for
preadmission services otherwise payable under the Medicare Outpatient
Prospective Payment System (OPPS) furnished to a beneficiary during the
day immediately preceding the date of admission to the IPF (see Sec.
413.40(c)(2)) and the overhead cost of maintaining the ED. This payment
is a facility-level adjustment that applies to all IPF admissions (with
one exception described below), regardless of whether a particular
patient receives preadmission services in the hospital's ED.
The ED adjustment is incorporated into the variable per diem
adjustment for the first day of each stay for IPFs with a qualifying
ED. That is, IPFs with a qualifying ED receive an adjustment factor of
1.31 as the variable per diem adjustment for day 1 of each stay. If an
IPF does not have a qualifying ED, it receives an adjustment factor of
1.19 as the variable per diem adjustment for day 1 of each patient
stay.
The ED adjustment is made on every qualifying claim except as
described below. As specified in Sec. 412.424(d)(1)(v)(B), the ED
adjustment is not made where a patient is discharged from an acute care
hospital or critical access hospital (CAH) and admitted to the same
hospital's or CAH's psychiatric unit. An ED adjustment is not made in
this case because the costs associated with ED services are reflected
in the DRG payment to the acute care hospital or through the reasonable
cost payment made to the CAH. If we provided the ED adjustment in these
cases, the hospital would be paid twice for the overhead costs of the
ED, as stated in the November 2004 IPF PPS final rule (69 FR 66960).
Therefore, when patients are discharged from an acute care hospital
or CAH and admitted to the same hospital's or CAH's psychiatric unit,
the IPF receives the 1.19 adjustment factor as the variable per diem
adjustment for the first day of the patient's stay in the IPF.
For RY 2011, we are retaining the 1.31 adjustment factor for IPFs
with qualifying EDs. A complete discussion of the steps involved in the
calculation of the ED adjustment factor appears in the November 2004
IPF PPS final rule (69 FR 66959 through 66960) and the May 2006 IPF PPS
final rule (71 FR 27070 through 27072).
D. Other Payment Adjustments and Policies
For RY 2011, the IPF PPS includes: An outlier adjustment to promote
access
[[Page 23120]]
to IPF care for those patients who require expensive care and to limit
the financial risk of IPFs treating unusually costly patients. In this
section, we also explain the reason for ending the stop-loss provision
that was applicable during the transition period.
1. Outlier Payments
In the November 2004 IPF PPS final rule, we implemented regulations
at Sec. 412.424(d)(3)(i) to provide a per-case payment for IPF stays
that are extraordinarily costly. Providing additional payments to IPFs
for extremely costly cases strongly improves the accuracy of the IPF
PPS in determining resource costs at the patient and facility level.
These additional payments reduce the financial losses that would
otherwise be incurred in treating patients who require more costly care
and, therefore, reduce the incentives for IPFs to under-serve these
patients.
We make outlier payments for discharges in which an IPF's estimated
total cost for a case exceeds a fixed dollar loss threshold amount
(multiplied by the IPF's facility-level adjustments) plus the Federal
per diem payment amount for the case.
In instances when the case qualifies for an outlier payment, we pay
80 percent of the difference between the estimated cost for the case
and the adjusted threshold amount for days 1 through 9 of the stay
(consistent with the median LOS for IPFs in FY 2002), and 60 percent of
the difference for day 10 and thereafter. We established the 80 percent
and 60 percent loss sharing ratios because we were concerned that a
single ratio established at 80 percent (like other Medicare PPSs) might
provide an incentive under the IPF per diem payment system to increase
LOS in order to receive additional payments. After establishing the
loss sharing ratios, we determined the current fixed dollar loss
threshold amount of $6,565 through payment simulations designed to
compute a dollar loss beyond which payments are estimated to meet the 2
percent outlier spending target.
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
In accordance with the update methodology described in Sec.
412.428(d), we are updating the fixed dollar loss threshold amount used
under the IPF PPS outlier policy. Based on the regression analysis and
payment simulations used to develop the IPF PPS, we established a 2
percent outlier policy which strikes an appropriate balance between
protecting IPFs from extraordinarily costly cases while ensuring the
adequacy of the Federal per diem base rate for all other cases that are
not outlier cases.
We believe it is necessary to update the fixed dollar loss
threshold amount because analysis of the latest available data (that
is, FY 2008 IPF claims) and rate increases indicates adjusting the
fixed dollar loss amount is necessary in order to maintain an outlier
percentage that equals 2 percent of total estimated IPF PPS payments.
In the May 2006 IPF PPS final rule (71 FR 27072), we describe the
process by which we calculate the outlier fixed dollar loss threshold
amount. We continue to use this process for RY 2011. We begin by
simulating aggregate payments with and without an outlier policy, and
applying an iterative process to determine an outlier fixed dollar loss
threshold amount that will result in outlier payments being equal to 2
percent of total estimated payments under the simulation. Based on this
process, we are updating the outlier fixed dollar loss threshold amount
to $6,372 to maintain estimated outlier payments at 2 percent of total
estimated IPF payments for RY 2011.
b. Statistical Accuracy of Cost-to-Charge Ratios
As previously stated, under the IPF PPS, an outlier payment is made
if an IPF's cost for a stay exceeds a fixed dollar loss threshold
amount. In order to establish an IPF's cost for a particular case, we
multiply the IPF's reported charges on the discharge bill by its
overall cost-to-charge ratio (CCR). This approach to determining an
IPF's cost is consistent with the approach used under the IPPS and
other PPSs. In FY 2004, we implemented changes to the IPPS outlier
policy used to determine CCRs for acute care hospitals because we
became aware that payment vulnerabilities resulted in inappropriate
outlier payments. Under the IPPS, we established a statistical measure
of accuracy for CCRs in order to ensure that aberrant CCR data did not
result in inappropriate outlier payments.
As we indicated in the November 2004 IPF PPS final rule, because we
believe that the IPF outlier policy is susceptible to the same payment
vulnerabilities as the IPPS, we adopted an approach to ensure the
statistical accuracy of CCRs under the IPF PPS (69 FR 66961).
Therefore, we adopted the following procedure in the November 2004 IPF
PPS final rule:
We calculated two national ceilings, one for IPFs located
in rural areas and one for IPFs located in urban areas. We computed the
ceilings by first calculating the national average and the standard
deviation of the CCR for both urban and rural IPFs.
To determine the rural and urban ceilings, we multiplied each of
the standard deviations by 3 and added the result to the appropriate
national CCR average (either rural or urban). The upper threshold CCR
for IPFs in RY 2011 is 1.7383 for rural IPFs, and 1.7377 for urban
IPFs, based on CBSA-based geographic designations. If an IPF's CCR is
above the applicable ceiling, the ratio is considered statistically
inaccurate and we assign the appropriate national (either rural or
urban) median CCR to the IPF.
We are applying the national CCRs to the following situations:
++ New IPFs that have not yet submitted their first Medicare cost
report.
++ IPFs whose overall CCR is in excess of 3 standard deviations
above the corresponding national geometric mean (that is, above the
ceiling).
++ Other IPFs for which the Medicare contractor obtains inaccurate
or incomplete data with which to calculate a CCR.
For new IPFs, we are using these national CCRs until the facility's
actual CCR can be computed using the first tentatively or final settled
cost report.
We are not making any changes to the procedures for ensuring the
statistical accuracy of CCRs in RY 2011. However, we are updating the
national urban and rural CCRs (ceilings and medians) for IPFs for RY
2011 based on the CCRs entered in the latest available IPF PPS Provider
Specific File.
The national CCRs for RY 2011 are 0.6480 for rural IPFs and 0.5170
for urban IPFs and will be used in each of the three situations listed
above. These calculations are based on the IPF's location (either urban
or rural) using the CBSA-based geographic designations.
A complete discussion regarding the national median CCRs appears in
the November 2004 IPF PPS final rule (69 FR 66961 through 66964).
2. Expiration of the Stop-Loss Provision
In the November 2004 IPF PPS final rule, we implemented a stop-loss
policy that reduced financial risk to IPFs projected to experience
substantial reductions in Medicare payments during the period of
transition to the IPF PPS. This stop-loss policy guaranteed that each
facility received total IPF PPS payments that were no less than 70
percent of its TEFRA payments had the IPF PPS not been implemented.
This policy was applied to the IPF PPS portion of Medicare payments
during the 3-year transition.
[[Page 23121]]
In the implementation year, the 70 percent of TEFRA payment stop-
loss policy required a reduction in the standardized Federal per diem
and ECT base rates of 0.39 percent in order to make the stop-loss
payments budget neutral. As described in the May 2008 IPF PPS notice
for RY 2009, we increased the Federal per diem base rate and ECT rate
by 0.39 percent because these rates were reduced by 0.39 percent in the
implementation year to ensure stop-loss payments were budget neutral.
The stop-loss provision ended during RY 2009 (that is for
discharges occurring on or after July 1, 2008 through June 30, 2009).
The stop-loss policy is no longer applicable under the IPF PPS.
V. Comments Beyond the Scope of the May 2009 IPF PPS Notice With
Request for Comments
In the May 2009 IPF PPS notice, which specifically solicited
comments on the IPF PPS teaching adjustment and the market basket, we
received several public comments which were outside the scope of that
notice. Below, we are providing a summary of the comments and our
response.
Comment: Two commenters recommended that CMS continue its study of
the wage index in favor of future changes that create a more equitable
system and adequately reimburse hospitals for providing quality care to
beneficiaries. The commenters recommend that the Bureau of Labor
Statistics (BLS) data approach be used to construct a hospital
compensation index. They support the elimination of the separate
Occupational Mix Survey documents and the large additional reporting
burden it creates for hospitals.
One commenter expressed concern that a large increase in the fixed
dollar threshold amount will significantly reduce the number of
inpatient cases eligible for outlier payments and consequently, further
reduce the ability of psychiatric facilities to provide necessary
psychiatric care to Medicare beneficiaries. The commenter recommends
that CMS continue examining its data to determine more specifically the
causes for the increase and if further analysis suggests that the
threshold increase is still valid, CMS should publish these reasons as
part of the final rule.
One commenter recommended that CMS revisit the Variable Per Diem
Adjustments that have been established in the November 2004 IPF PPS
final rule (69 FR 66946) and to validate these adjustments based on
current claim information. The commenter believes the current system
does not reflect all factors affecting cost. The example cited was that
inpatient prospective payment system facilities receive a special
payment treatment for servicing a disproportionate share of low-income
patients, which is intended to reimburse a facility for additional cost
incurred for handling such patients. The commenter stated that the
current IPF PPS payment system does not consider this type of patient
in its payment mechanism.
Response: We are not addressing these comments in this notice
because they are beyond the scope of the May 2009 notice. However, we
will consider the comments and decide whether to take actions based on
the information or recommendations of the commenters in future
rulemaking.
VI. Waiver of Proposed Rulemaking
We ordinarily publish a notice of proposed rulemaking in the
Federal Register to provide a period for public comment before the
provisions of a rule take effect. We can waive this procedure, however,
if we find good cause that notice and comment procedures are
impracticable, unnecessary, or contrary to the public interest and we
incorporate a statement of finding and its reasons in the notice. We
find it is unnecessary to undertake notice and comment rulemaking for
the update in this notice because the update does not make any
substantive changes in policy, but merely reflects the application of
previously established methodologies. In addition, new section
1886(s)(3)(A) of the Act requires the application of an ``Other
Adjustment'' to the update to the IPF PPS base rate in RY 2011. We
applied the statutorily-required adjustment in this notice. We find
that notice and comment rulemaking is unnecessary to implement that
statutory provision because it is a self-implementing provision of law,
not requiring the exercise of any discretion on the part of CMS.
Therefore, under 5 U.S.C. 553(b)(3)(B), for good cause, we waive notice
and comment procedures.
VII. Collection of Information Requirements
This document does not impose any 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).
VIII. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this notice as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the September 19, 1980 Regulatory Flexibility Act (RFA) (Pub. L. 96-
354), section 1102(b) of the Act, the Unfunded Mandates Reform Act of
1995 (Pub. L. 104-4), Executive Order 13132 on Federalism, and the
Congressional Review Act (5 U.S.C. 804(2)).
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 in any 1 year). Although this
notice does not meet the $100 million threshold established by
Executive Order 12866, we are considering this notice to be
``economically significant'' because the redistributive effects are
estimated to be close to constituting a shift of $100 million. For
purposes of Title 5, United States Code, section 804(2), we estimate
that this rulemaking is ``economically significant'', and is also a
major rule under the Congressional Review Act. Accordingly, we have
prepared a Regulatory Impact Analysis that to the best of our ability
presents the costs and benefits of the rulemaking on the 1,679 IPFs.
The updates to the IPF labor-related share and wage indices are
made in a budget neutral manner and thus have no effect on estimated
costs to the Medicare program. Therefore, the estimated increased cost
to the Medicare program is due to the update to the IPF payment rates,
which results in an approximate $91 million increase in payments (due
to the 2.4% market basket increase with the 0.25% ``Other Adjustment''
reduction, as required by new section 1886(a)(3)(A) of the Act, and the
update to the outlier fixed dollar loss threshold amount, which results
in about a $4 million increase in payments). The distribution of these
impacts is summarized in Table 13. The net effect of the updates
described in this notice results in an overall estimated $95 million
increase in payments from RY 2010 to RY 2011.
The RFA requires agencies to analyze options for regulatory relief
of small businesses, if a rule has a significant impact on a
substantial number of small entities. For purposes of the RFA, we
estimate that the great majority of IPFs are small entities as that
term is used in the RFA (include small businesses, nonprofit
organizations, and small
[[Page 23122]]
governmental jurisdictions). The majority of hospitals and most other
health care providers and suppliers are small entities, either by being
nonprofit organizations or by meeting the SBA definition of a small
business (having revenues of $7 million to $34.5 million in any 1
year). (For details, see the Small Business Administration's Interim
final rule that set forth size standards at 70 FR 72577, December 6,
2005.) Because we lack data on individual hospital receipts, we cannot
determine the number of small proprietary IPFs or the proportion of
IPFs' revenue that is derived from Medicare payments. Therefore, we
assume that all IPFs are considered small entities. The Department of
Health and Human Services (HHS) generally uses a revenue impact of 3 to
5 percent as a significance threshold under the RFA. As shown in Table
13, we estimate that the net revenue impact of this notice on all IPFs
is to increase estimated payments by about 2.26 percent. Since the
estimated impact of this notice is a net increase in revenue across all
categories of IPFs, we believe that this notice would not impose a
significant burden on small entities. Medicare fiscal intermediaries
and carriers are not considered to be small entities. Individuals and
States are not included in the definition of a small entity.
Although section 1102(b) of the Act applies to regulations for
which a proposed rule is published, the HHS policy is to prepare an
analysis of the impact on small rural hospitals for any regulation
published. As a result, we are voluntarily determining whether this
notice will have a significant impact on the operations of a
substantial number of small rural hospitals. 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 an MSA. As discussed in
detail below, the rates and policies set forth in this notice will not
have an adverse impact on the rural hospitals based on the data of the
312 rural units and 64 rural hospitals in our database of 1,679 IPFs
for which data were available.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2010, that
threshold is approximately $135 million. This notice will not impose
spending costs on State, local, or Tribal governments in the aggregate,
or by the private sector, of $135 million.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. We have reviewed this notice under the criteria set forth
in Executive Order 13132 and have determined that the notice will not
have any substantial direct impact on State or local governments,
preempt State law, or otherwise have a Federalism implication.
B. Anticipated Effects
We discuss below the historical background of the IPF PPS and the
impact of this notice on the Federal Medicare budget and on IPFs.
1. Budgetary Impact
As discussed in the November 2004 and May 2006 IPF PPS final rules,
we applied a budget neutrality factor to the Federal per diem and ECT
base rates to ensure that total estimated payments under the IPF PPS in
the implementation period would equal the amount that would have been
paid if the IPF PPS had not been implemented. The budget neutrality
factor includes the following components: Outlier adjustment, stop-loss
adjustment, and the behavioral offset. As discussed in the May 2008 IPF
PPS notice (73 FR 25711), the stop-loss adjustment is no longer
applicable under the IPF PPS.
In accordance with Sec. 412.424(c)(3)(ii), we indicated that we
would evaluate the accuracy of the budget neutrality adjustment within
the first 5 years after implementation of the payment system. We may
make a one-time prospective adjustment to the Federal per diem and ECT
base rates to account for differences between the historical data on
cost-based TEFRA payments (the basis of the budget neutrality
adjustment) and estimates of TEFRA payments based on actual data from
the first year of the IPF PPS. As part of that process, we will
reassess the accuracy of all of the factors impacting budget
neutrality.
In addition, as discussed in section III.B.2 of this notice, we are
using the wage index and labor market share in a budget neutral manner
by applying a wage index budget neutrality factor to the Federal per
diem and ECT base rates. Therefore, the budgetary impact to the
Medicare program by this update to the IPF PPS will be due to the
market basket update (see section III.B.2.a of this notice) with the
``Other Adjustment,'' as required by new section 1886(s)(3)(A) of the
Act, and the update to the outlier fixed dollar loss threshold amount.
2. Impacts on Providers
To understand the impact of the changes to the IPF PPS on
providers, discussed in this notice, it is necessary to compare
estimated payments under the IPF PPS rates and factors for RY 2011
versus those under RY 2010. The estimated payments for RY 2010 and RY
2011 will be 100 percent of the IPF PPS payment, since the transition
period has ended and stop-loss payments are no longer paid. We
determined the percent change of estimated RY 2011 IPF PPS payments to
estimated RY 2010 IPF PPS payments for each category of IPFs. In
addition, for each category of IPFs, we have included the estimated
percent change in payments resulting from the update to the outlier
fixed dollar loss threshold amount, the wage index changes for the RY
2011 IPF PPS, and the market basket update, as adjusted by the ``Other
Adjustment''.
To illustrate the impacts of the final RY 2011 changes in this
notice, our analysis begins with an RY 2010 baseline simulation model
based on FY 2008 IPF payments inflated to the midpoint of RY 2010 using
IHS Global Insight's most recent forecast of the market basket update
(see section III.2.b of this notice); the estimated outlier payments in
RY 2010; the CBSA designations for IPFs based on OMB's MSA definitions
after June 2003; the FY 2009 pre-floor, pre-reclassified hospital wage
index; the RY 2010 labor-market share; and the RY 2010 percentage
amount of the rural adjustment. During the simulation, the total
estimated outlier payments are maintained at 2 percent of total
estimated IPF PPS payments.
Each of the following changes is added incrementally to this
baseline model in order for us to isolate the effects of each change:
The update to the outlier fixed dollar loss threshold
amount.
The FY 2010 pre-floor, pre-reclassified hospital wage
index and RY 2011 final labor-related share.
Our final comparison illustrates the percent change in
payments from RY 2010 (that is, July 1, 2009 to June 30, 2010) to RY
2011 (that is, July 1, 2010 to June 30, 2011) and includes a 2.4
percent market basket update to the IPF PPS base rates with a -0.25%
``Other Adjustment'' to the IPF PPS base rates, as required by new
section 1886(s)(3)(A) of the Act.
[[Page 23123]]
Table 13--Projected Impacts
----------------------------------------------------------------------------------------------------------------
Projected impacts (% Change)
-----------------------------------------------------------------------------------------------------------------
Total with
Number of CBSA wage market basket
Facility by type facilities Outlier index & labor & other
share adjustment \1\
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
All Facilities.................................. 1,679 0.11 0.00 2.26
Total Urban..................................... 1,303 0.11 0.02 2.28
Total Rural..................................... 376 0.09 -0.10 2.14
Urban DPU....................................... 899 0.15 -0.01 2.29
Urban CAH unit.................................. 14 0.35 -0.30 2.20
Urban hospital.................................. 390 0.03 0.07 2.26
Rural DPU....................................... 259 0.11 -0.13 2.13
Rural CAH unit.................................. 53 0.06 0.17 2.39
Rural hospital.................................. 64 0.03 -0.13 2.05
Freestanding IPF By Type of Ownership:
Urban Psychiatric Hospitals:
Government.............................. 170 0.03 0.03 2.22
Non-Profit.............................. 115 0.03 0.16 2.35
For-Profit.............................. 105 0.03 0.02 2.20
Rural Psychiatric Hospitals:
Government.............................. 41 0.03 -0.51 1.66
Non-Profit.............................. 10 0.04 0.20 2.40
For-Profit.............................. 13 0.01 0.88 3.06
IPF Units By Type of Ownership:
Urban DPU:
Government.............................. 156 0.23 0.30 2.69
Non-Profit.............................. 616 0.14 -0.13 2.17
For-Profit.............................. 127 0.10 0.12 2.37
Urban CAH:
Government.............................. 5 0.53 -1.61 1.03
Non-Profit.............................. 8 0.28 0.13 2.56
For-Profit.............................. 1 0.03 3.18 5.43
Rural DPU:
Government.............................. 61 0.12 0.08 2.35
Non-Profit.............................. 150 0.11 -0.26 2.00
For-Profit.............................. 48 0.11 -0.03 2.24
Rural CAH:
Government.............................. 21 0.05 0.43 2.64
Non-Profit.............................. 28 0.07 -0.01 2.21
For-Profit.............................. 4 0.07 0.09 2.32
By Teaching Status:
Non-teaching................................ 1,442 0.10 -0.03 2.22
Less than 10% interns and residents to beds. 131 0.11 0.15 2.42
10% to 30% interns and residents to beds.... 73 0.19 0.07 2.41
More than 30% interns and residents to beds. 33 0.27 -0.11 2.31
By Region:
New England................................. 118 0.15 0.52 2.83
Mid-Atlantic................................ 285 0.09 -0.04 2.20
South Atlantic.............................. 234 0.09 -0.03 2.21
East North Central.......................... 284 0.14 -0.40 1.88
East South Central.......................... 167 0.08 0.01 2.24
West North Central.......................... 149 0.11 0.07 2.33
West South Central.......................... 228 0.09 -0.08 2.16
Mountain.................................... 85 0.11 0.67 2.95
Pacific..................................... 129 0.15 0.02 2.32
By Bed Size:
Psychiatric Hospitals:
Under 12 beds........................... 3 0.01 -0.31 1.84
Beds: 12-24............................. 64 0.08 0.60 2.85
Beds: 25-49............................. 69 0.08 0.09 2.32
Beds: 50-75............................. 74 0.04 0.58 2.78
Over 75 beds............................ 244 0.02 -0.13 2.03
Psychiatric Units:
Under 12 beds........................... 191 0.18 -0.09 2.24
Beds: 12-24............................. 529 0.16 -0.16 2.14
Beds: 25-49............................. 335 0.14 0.00 2.30
Beds: 50-75............................. 106 0.13 -0.15 2.13
[[Page 23124]]
Over 75 beds............................ 64 0.13 0.36 2.65
----------------------------------------------------------------------------------------------------------------
\1\ This column shows changes in payments from RY 2010 to RY 2011. It reflects the impact of the RY 2011 market
basket update with the ``Other Adjustment'' for the rate year beginning in 2010, as required by new section
1886(s)(3)(A) of the Act. The RY 2011 market basket update is 2.4% and the ``Other Adjustment'' for the rate
year beginning in 2010 is -0.25%. It incorporates all of the changes displayed in Columns 3 and 4. The product
of these impacts may be different from the percentage changes shown here due to rounding effects.
3. Results
Table 13 above displays the results of our analysis. The table
groups IPFs into the categories listed below based on characteristics
provided in the Provider of Services (POS) file, the IPF provider
specific file, and cost report data from HCRIS:
Facility Type.
Location.
Teaching Status Adjustment.
Census Region.
Size.
The top row of the table shows the overall impact on the 1,679 IPFs
included in the analysis.
In column 3, we present the effects of the update to the outlier
fixed dollar loss threshold amount. We estimate total outlier payments
in RY 2010 to be approximately 1.9 percent of total estimated payments.
Therefore, we are updating the threshold from $6,565 in RY 2010 to
$6,372 in RY 2011 in order to maintain total estimated outlier payments
equal to 2 percent of total estimated payments for RY 2011. The overall
aggregate effect of this change (as shown in column 3 of table 13),
across all hospital groups, is to increase total estimated payments to
IPFs by about 0.11 percent. All categories of IPFs are projected to
receive either an increase or no change in payments. There are
distributional effects of this change among different categories of
IPFs. Urban and rural, freestanding psychiatric hospitals; urban, for-
profit IPF units located in CAHs; and psychiatric hospitals with under
12 beds and 50 or more will experience approximately a zero percent
change in their payments. Alternatively, urban, government IPF units
located in CAHs will receive the largest increase of 0.53 percent.
In column 4, we present the effects of the budget-neutral update to
the labor-related share and the wage index adjustment under the CBSA
geographic area definitions announced by OMB in June 2003. This is a
comparison of the simulated RY 2011 payments under the FY 2010 hospital
wage index under CBSA classification and associated labor-related share
to the simulated RY 2010 payments under the FY 2009 hospital wage index
under CBSA classifications and associated labor-related share. We note
that there is no projected change in aggregate payments to IPFs, as
indicated in the first row of column 4. However, there would be
distributional effects among different categories of IPFs. For example,
urban, government IPF units located in CAHs will experience a 1.61
percent decrease in payments. An urban, for-profit IPF CAH unit will
receive the largest increase of 3.18 percent.
Column 5 compares our estimates of the changes reflected in this
notice for RY 2011, to our estimates of payments for RY 2010 (without
these changes). This column reflects all RY 2011 changes relative to RY
2010 (as shown in columns 3 and 4 and including the market basket
update with the -.25% ``Other Adjustment''). The average increase for
all IPFs is approximately 2.26 percent. This increase includes the
effects of the market basket update (2.4%) with the ``Other
Adjustment'' (-0.25%) resulting in a 2.15 percent increase in total RY
2011 payments, and an approximate 0.11 percent increase in RY 2011
payments due to the update to the outlier fixed dollar loss threshold.
Overall, the largest payment increases ranging from 3.06 percent to
5.43 percent are projected to be among rural, for-profit freestanding
IPFs and urban, for-profit IPF units located in CAHs. Urban, government
IPF units located in CAHs will receive the smallest increase of 1.03
percent.
4. Effect on the Medicare Program
Based on actuarial projections resulting from our experience with
other PPSs, we estimate that Medicare spending (total Medicare program
payments) for IPF services over the next 5 years would be as shown in
Table 14 below.
Table 14--Estimated Payments
------------------------------------------------------------------------
Dollars
Rate year in
millions
------------------------------------------------------------------------
July 1, 2010 to June 30, 2011................................ $4,438
July 1, 2011 to June 30, 2012................................ 4,685
July 1, 2012 to June 30, 2013................................ 4,930
July 1, 2013 to June 30, 2014................................ 5,178
July 1, 2014 to June 30, 2015................................ 5,450
------------------------------------------------------------------------
These estimates are based on the current forecast of the increases
in the RPL market basket, including an adjustment for productivity, for
which we are using a preliminary estimate, for the rate year beginning
in 2012 and each subsequent rate year, as required by new section
1886(s)(3)(A) of the Act, as follows:
2.4 percent for rate years beginning in 2010 (RY 2011).
2.9 percent for rate years beginning in 2011 (RY 2012).
1.7 percent for rate years beginning in 2012 (RY 2013).
1.9 percent for rate years beginning in 2013 (RY 2014).
2.1 percent for rate years beginning in 2014 (RY 2015).
The estimates in Table 14 also include the application of the
``Other Adjustment,'' as required by section 1886(s)(A)(3) of the Act,
as follows:
-0.25 percent for rate years beginning in 2010.
-0.25 percent for rate years beginning in 2011.
-0.1 percent for rate years beginning in 2012.
-0.1 percent for rate years beginning in 2013.
-0.3 percent for rate years beginning in 2014.
We estimate that there would be a change in fee-for-service
Medicare beneficiary enrollment as follows:
2.5 percent in RY 2011.
3.2 percent in RY 2012.
3.1 percent in RY 2013.
[[Page 23125]]
3.1 percent in RY 2014.
2.8 percent in RY 2015.
5. Effect on Beneficiaries
Under the IPF PPS, IPFs will receive payment based on the average
resources consumed by patients for each day. We do not expect changes
in the quality of care or access to services for Medicare beneficiaries
under the RY 2011 IPF PPS. In fact, we believe that access to IPF
services will be enhanced due to the patient- and facility-level
adjustment factors, all of which are intended to adequately reimburse
IPFs for expensive cases. Finally, the outlier policy is intended to
assist IPFs that experience high-cost cases.
C. Alternatives Considered
The statute does not specify an update strategy for the IPF PPS and
is broadly written to give the Secretary discretion in establishing an
update methodology. Therefore, we are updating the IPF PPS using the
methodology published in the November 2004 IPF PPS final rule.
We note that this notice does not initiate any policy changes with
regard to the IPF PPS; rather, it simply provides an update to the
rates for RY 2011. Therefore, no options were considered.
D. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 15 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this notice. This table
provides our best estimate of the increase in Medicare payments under
the IPF PPS notice, as a result of the changes presented in this
notice, and based on the data for 1,679 IPFs in our database. All
expenditures are classified as transfers to Medicare providers (that
is, IPFs).
Table 15--Accounting Statement: Classification of Estimated
Expenditures, From the 2010 IPF PPS RY to the 2011 IPF PPS RY
[In millions]
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $95.
From Whom To Whom? Federal Government To IPF
Medicare Providers.
------------------------------------------------------------------------
In accordance with the provisions of Executive Order 12866, this
notice was reviewed by OMB.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: March 4, 2010.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: April 20, 2010.
Kathleen Sebelius,
Secretary.
Addendum A--Rate and Adjustment Factors
Per Diem Rate
------------------------------------------------------------------------
------------------------------------------------------------------------
Federal Per Diem Base Rate.................................... $665.71
Labor Share (0.75400)......................................... 501.95
Non-Labor Share (0.24600)..................................... 163.76
------------------------------------------------------------------------
Fixed Dollar Loss Threshold Amount: $6,372.
Wage Index Budget Neutrality Factor: 0.9999.
Facility Adjustments
------------------------------------------------------------------------
------------------------------------------------------------------------
Rural Adjustment Factor................... 1.17.
Teaching Adjustment Factor................ 0.5150.
Wage Index................................ Pre-reclass Hospital Wage
Index (FY 2010).
------------------------------------------------------------------------
Cost of Living Adjustments (COLAs)
------------------------------------------------------------------------
------------------------------------------------------------------------
Alaska
------------------------------------------------------------------------
Anchorage..................................................... 1.23
Fairbanks..................................................... 1.23
Juneau........................................................ 1.23
Rest of Alaska................................................ 1.25
------------------------------------------------------------------------
Hawaii
------------------------------------------------------------------------
Honolulu County............................................... 1.25
Hawaii County................................................. 1.18
Kauai County.................................................. 1.25
Maui County................................................... 1.25
Kalawao County................................................ 1.25
------------------------------------------------------------------------
Patient Adjustments
------------------------------------------------------------------------
------------------------------------------------------------------------
ECT--Per Treatment............................................ $286.60
------------------------------------------------------------------------
Variable Per Diem Adjustments
------------------------------------------------------------------------
Adjustment
factor
------------------------------------------------------------------------
Day 1--Facility Without a Qualifying Emergency Department.. 1.19
Day 1--Facility With a Qualifying Emergency Department..... 1.31
Day 2...................................................... 1.12
Day 3...................................................... 1.08
Day 4...................................................... 1.05
Day 5...................................................... 1.04
Day 6...................................................... 1.02
Day 7...................................................... 1.01
Day 8...................................................... 1.01
Day 9...................................................... 1.00
Day 10..................................................... 1.00
Day 11..................................................... 0.99
Day 12..................................................... 0.99
Day 13..................................................... 0.99
Day 14..................................................... 0.99
Day 15..................................................... 0.98
Day 16..................................................... 0.97
Day 17..................................................... 0.97
Day 18..................................................... 0.96
Day 19..................................................... 0.95
Day 20..................................................... 0.95
Day 21..................................................... 0.95
After Day 21............................................... 0.92
------------------------------------------------------------------------
Age Adjustments
------------------------------------------------------------------------
Adjustment
Age (in years) factor
------------------------------------------------------------------------
Under 45................................................... 1.00
45 and under 50............................................ 1.01
50 and under 55............................................ 1.02
55 and under 60............................................ 1.04
60 and under 65............................................ 1.07
65 and under 70............................................ 1.10
70 and under 75............................................ 1.13
75 and under 80............................................ 1.15
80 and over................................................ 1.17
------------------------------------------------------------------------
DRG Adjustments
----------------------------------------------------------------------------------------------------------------
Adjustment
MS-DRG MS-DRG descriptions factor
----------------------------------------------------------------------------------------------------------------
056........................................ Degenerative nervous system disorders w MCC........... 1.05
[[Page 23126]]
057........................................ Degenerative nervous system disorders w/o MCC.........
080........................................ Nontraumatic stupor & coma w MCC...................... 1.07
081........................................ Nontraumatic stupor & coma w/o MCC....................
876........................................ O.R. procedure w principal diagnoses of mental illness 1.22
880........................................ Acute adjustment reaction & psychosocial dysfunction.. 1.05
881........................................ Depressive neuroses................................... 0.99
882........................................ Neuroses except depressive............................ 1.02
883........................................ Disorders of personality & impulse control............ 1.02
884........................................ Organic disturbances & mental retardation............. 1.03
885........................................ Psychoses............................................. 1.00
886........................................ Behavioral & developmental disorders.................. 0.99
887........................................ Other mental disorder diagnoses....................... 0.92
894........................................ Alcohol/drug abuse or dependence, left AMA............ 0.97
895........................................ Alcohol/drug abuse or dependence w rehabilitation 1.02
therapy.
896........................................ Alcohol/drug abuse or dependence w/o rehabilitation 0.88
therapy w MCC.
897........................................ Alcohol/drug abuse or dependence w/o rehabilitation
therapy w/o MCC.
----------------------------------------------------------------------------------------------------------------
Comorbidity Adjustments
------------------------------------------------------------------------
Adjustment
Comorbidity factor
------------------------------------------------------------------------
Developmental Disabilities................................. 1.04
Coagulation Factor Deficit................................. 1.13
Tracheostomy............................................... 1.06
Eating and Conduct Disorders............................... 1.12
Infectious Diseases........................................ 1.07
Renal Failure, Acute....................................... 1.11
Renal Failure, Chronic..................................... 1.11
Oncology Treatment......................................... 1.07
Uncontrolled Diabetes Mellitus............................. 1.05
Severe Protein Malnutrition................................ 1.13
Drug/Alcohol Induced Mental Disorders...................... 1.03
Cardiac Conditions......................................... 1.11
Gangrene................................................... 1.10
Chronic Obstructive Pulmonary Disease...................... 1.12
Artificial Openings--Digestive & Urinary................... 1.08
Severe Musculoskeletal & Connective Tissue Diseases........ 1.09
Poisoning.................................................. 1.11
------------------------------------------------------------------------
Addendum B--RY 2011 CBSA Wage Index Tables
In this addendum, we provide Tables 1 and 2 which indicate the
CBSA-based wage index values for urban and rural providers.
Table 1--RY 2011 Wage Index For Urban Areas Based on CBSA Labor Market
Areas
------------------------------------------------------------------------
Wage
CBSA code Urban area (constituent counties) index
------------------------------------------------------------------------
10180.................... Abilene, TX........................ 0.7946
Callahan County, TX
Jones County, TX
Taylor County, TX
10380.................... Aguadilla-Isabela-San 0.3462
Sebasti[aacute]n, PR.
Aguada Municipio, PR
Aguadilla Municipio, PR
A[ntilde]asco Municipio, PR
Isabela Municipio, PR
Lares Municipio, PR
Moca Municipio, PR
Rinc[oacute]n Municipio, PR
San Sebasti[aacute]n Municipio, PR
10420.................... Akron, OH.......................... 0.8850
Portage County, OH
Summit County, OH
10500.................... Albany, GA......................... 0.8899
[[Page 23127]]
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580.................... Albany-Schenectady-Troy, NY........ 0.8777
Albany County, NY
Rensselaer County, NY
Saratoga County, NY
Schenectady County, NY
Schoharie County, NY
10740.................... Albuquerque, NM.................... 0.9399
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780.................... Alexandria, LA..................... 0.8012
Grant Parish, LA
Rapides Parish, LA
10900.................... Allentown-Bethlehem-Easton, PA-NJ.. 0.9611
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
11020.................... Altoona, PA........................ 0.8863
Blair County, PA
11100.................... Amarillo, TX....................... 0.8689
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180.................... Ames, IA........................... 0.9493
Story County, IA
11260.................... Anchorage, AK...................... 1.2013
Anchorage Municipality, AK
Matanuska-Susitna Borough, AK
11300.................... Anderson, IN....................... 0.9052
Madison County, IN
11340.................... Anderson, SC....................... 0.9023
Anderson County, SC
11460.................... Ann Arbor, MI...................... 1.0293
Washtenaw County, MI
11500.................... Anniston-Oxford, AL................ 0.7643
Calhoun County, AL
11540.................... Appleton, WI....................... 0.9289
Calumet County, WI
Outagamie County, WI
11700.................... Asheville, NC...................... 0.9057
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
12020.................... Athens-Clarke County, GA........... 0.9492
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060.................... Atlanta-Sandy Springs-Marietta, GA. 0.9591
Barrow County, GA
Bartow County, GA
Butts County, GA
Carroll County, GA
Cherokee County, GA
Clayton County, GA
Cobb County, GA
Coweta County, GA
Dawson County, GA
DeKalb County, GA
Douglas County, GA
Fayette County, GA
Forsyth County, GA
[[Page 23128]]
Fulton County, GA
Gwinnett County, GA
Haralson County, GA
Heard County, GA
Henry County, GA
Jasper County, GA
Lamar County, GA
Meriwether County, GA
Newton County, GA
Paulding County, GA
Pickens County, GA
Pike County, GA
Rockdale County, GA
Spalding County, GA
Walton County, GA
12100.................... Atlantic City-Hammonton, NJ........ 1.1554
Atlantic County, NJ
12220.................... Auburn-Opelika, AL................. 0.8138
Lee County, AL
12260.................... Augusta-Richmond County, GA-SC..... 0.9409
Burke County, GA
Columbia County, GA
McDuffie County, GA
Richmond County, GA
Aiken County, SC
Edgefield County, SC
12420.................... Austin-Round Rock, TX.............. 0.9518
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540.................... Bakersfield, CA.................... 1.1232
Kern County, CA
12580.................... Baltimore-Towson, MD............... 1.0214
Anne Arundel County, MD
Baltimore County, MD
Carroll County, MD
Harford County, MD
Howard County, MD
Queen Anne's County, MD
Baltimore City, MD
12620.................... Bangor, ME......................... 1.0154
Penobscot County, ME
12700.................... Barnstable Town, MA................ 1.2618
Barnstable County, MA
12940.................... Baton Rouge, LA.................... 0.8180
Ascension Parish, LA
East Baton Rouge Parish, LA
East Feliciana Parish, LA
Iberville Parish, LA
Livingston Parish, LA
Pointe Coupee Parish, LA
St. Helena Parish, LA
West Baton Rouge Parish, LA
West Feliciana Parish, LA
12980.................... Battle Creek, MI................... 1.0000
Calhoun County, MI
13020.................... Bay City, MI....................... 0.9267
Bay County, MI
13140.................... Beaumont-Port Arthur, TX........... 0.8383
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380.................... Bellingham, WA..................... 1.1395
Whatcom County, WA
13460.................... Bend, OR........................... 1.1446
Deschutes County, OR
13644.................... Bethesda-Frederick-Gaithersburg, MD 1.0298
Frederick County, MD
Montgomery County, MD
[[Page 23129]]
13740.................... Billings, MT....................... 0.8781
Carbon County, MT
Yellowstone County, MT
13780.................... Binghamton, NY..................... 0.8780
Broome County, NY
Tioga County, NY
13820.................... Birmingham-Hoover, AL.............. 0.8554
Bibb County, AL
Blount County, AL
Chilton County, AL
Jefferson County, AL
St. Clair County, AL
Shelby County, AL
Walker County, AL
13900.................... Bismarck, ND....................... 0.7637
Burleigh County, ND
Morton County, ND
13980.................... Blacksburg-Christiansburg-Radford, 0.8394
VA.
Giles County, VA
Montgomery County, VA
Pulaski County, VA
Radford City, VA
14020.................... Bloomington, IN.................... 0.9043
Greene County, IN
Monroe County, IN
Owen County, IN
14060.................... Bloomington-Normal, IL............. 0.9378
McLean County, IL
14260.................... Boise City-Nampa, ID............... 0.9318
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee County, ID
14484.................... Boston-Quincy, MA.................. 1.2186
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500.................... Boulder, CO........................ 1.0266
Boulder County, CO
14540.................... Bowling Green, KY.................. 0.8469
Edmonson County, KY
Warren County, KY
14600.................... Bradenton-Sarasota-Venice, FL...... 0.9735
Manatee County, FL
Sarasota County, FL
14740.................... Bremerton-Silverdale, WA........... 1.0755
Kitsap County, WA
14860.................... Bridgeport-Stamford-Norwalk, CT.... 1.2792
Fairfield County, CT
15180.................... Brownsville-Harlingen, TX.......... 0.9020
Cameron County, TX
15260.................... Brunswick, GA...................... 0.9178
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380.................... Buffalo-Niagara Falls, NY.......... 0.9740
Erie County, NY
Niagara County, NY
15500.................... Burlington, NC..................... 0.8749
Alamance County, NC
15540.................... Burlington-South Burlington, VT.... 1.0106
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764.................... Cambridge-Newton-Framingham, MA.... 1.1278
Middlesex County, MA
15804.................... Camden, NJ......................... 1.0374
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
[[Page 23130]]
15940.................... Canton-Massillon, OH............... 0.8813
Carroll County, OH
Stark County, OH
15980.................... Cape Coral-Fort Myers, FL.......... 0.9076
Lee County, FL
16020.................... Cape Girardeau-Jackson, MO-IL...... 0.9047
Alexander County, IL
Bollinger County, MO
Cape Girardeau County, MO
16180.................... Carson City, NV.................... 1.0531
Carson City, NV
16220.................... Casper, WY......................... 0.9520
Natrona County, WY
16300.................... Cedar Rapids, IA................... 0.8984
Benton County, IA
Jones County, IA
Linn County, IA
16580.................... Champaign-Urbana, IL............... 1.0108
Champaign County, IL
Ford County, IL
Piatt County, IL
16620.................... Charleston, WV..................... 0.8141
Boone County, WV
Clay County, WV
Kanawha County, WV
Lincoln County, WV
Putnam County, WV
16700.................... Charleston-North Charleston- 0.9279
Summerville, SC.
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740.................... Charlotte-Gastonia-Concord, 0.9474
NC[dash]SC.
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820.................... Charlottesville, VA................ 0.9372
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860.................... Chattanooga, TN-GA................. 0.8831
Catoosa County, GA
Dade County, GA
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940.................... Cheyenne, WY....................... 0.9344
Laramie County, WY
16974.................... Chicago-Naperville-Joliet, IL...... 1.0471
Cook County, IL
DeKalb County, IL
DuPage County, IL
Grundy County, IL
Kane County, IL
Kendall County, IL
McHenry County, IL
Will County, IL
17020.................... Chico, CA.......................... 1.1198
Butte County, CA
17140.................... Cincinnati-Middletown, OH-KY-IN.... 0.9483
Dearborn County, IN
Franklin County, IN
Ohio County, IN
Boone County, KY
Bracken County, KY
Campbell County, KY
[[Page 23131]]
Gallatin County, KY
Grant County, KY
Kenton County, KY
Pendleton County, KY
Brown County, OH
Butler County, OH
Clermont County, OH
Hamilton County, OH
Warren County, OH
17300.................... Clarksville, TN-KY................. 0.7980
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420.................... Cleveland, TN...................... 0.7564
Bradley County, TN
Polk County, TN
17460.................... Cleveland-Elyria-Mentor, OH........ 0.8914
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Medina County, OH
17660.................... Coeur d'Alene, ID.................. 0.9235
Kootenai County, ID
17780.................... College Station-Bryan, TX.......... 0.9498
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820.................... Colorado Springs, CO............... 0.9821
El Paso County, CO
Teller County, CO
17860.................... Columbia, MO....................... 0.8618
Boone County, MO
Howard County, MO
17900.................... Columbia, SC....................... 0.8789
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980.................... Columbus, GA-AL.................... 0.8724
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
Muscogee County, GA
18020.................... Columbus, IN....................... 0.9536
Bartholomew County, IN
18140.................... Columbus, OH....................... 1.0101
Delaware County, OH
Fairfield County, OH
Franklin County, OH
Licking County, OH
Madison County, OH
Morrow County, OH
Pickaway County, OH
Union County, OH
18580.................... Corpus Christi, TX................. 0.8693
Aransas County, TX
Nueces County, TX
San Patricio County, TX
18700.................... Corvallis, OR...................... 1.1002
Benton County, OR
19060.................... Cumberland, MD-WV.................. 0.8045
Allegany County, MD
Mineral County, WV
19124.................... Dallas-Plano-Irving, TX............ 0.9853
Collin County, TX
Dallas County, TX
[[Page 23132]]
Delta County, TX
Denton County, TX
Ellis County, TX
Hunt County, TX
Kaufman County, TX
Rockwall County, TX
19140.................... Dalton, GA......................... 0.8666
Murray County, GA
Whitfield County, GA
19180.................... Danville, IL....................... 0.8738
Vermilion County, IL
19260.................... Danville, VA....................... 0.8323
Pittsylvania County, VA
Danville City, VA
19340.................... Davenport-Moline-Rock Island, IA-IL 0.8284
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380.................... Dayton, OH......................... 0.9211
Greene County, OH
Miami County, OH
Montgomery County, OH
Preble County, OH
19460.................... Decatur, AL........................ 0.7799
Lawrence County, AL
Morgan County, AL
19500.................... Decatur, IL........................ 0.7995
Macon County, IL
19660.................... Deltona-Daytona Beach-Ormond Beach, 0.8865
FL.
Volusia County, FL
19740.................... Denver-Aurora-Broomfield, CO....... 1.0731
Adams County, CO
Arapahoe County, CO
Broomfield County, CO
Clear Creek County, CO
Denver County, CO
Douglas County, CO
Elbert County, CO
Gilpin County, CO
Jefferson County, CO
Park County, CO
19780.................... Des Moines-West Des Moines, IA..... 0.9649
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
Warren County, IA
19804.................... Detroit-Livonia-Dearborn, MI....... 0.9729
Wayne County, MI
20020.................... Dothan, AL......................... 0.7406
Geneva County, AL
Henry County, AL
Houston County, AL
20100.................... Dover, DE.......................... 0.9931
Kent County, DE
20220.................... Dubuque, IA........................ 0.8869
Dubuque County, IA
20260.................... Duluth, MN-WI...................... 1.0448
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500.................... Durham-Chapel Hill, NC............. 0.9618
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740.................... Eau Claire, WI..................... 0.9567
Chippewa County, WI
Eau Claire County, WI
20764.................... Edison-New Brunswick, NJ........... 1.1061
[[Page 23133]]
Middlesex County, NJ
Monmouth County, NJ
Ocean County, NJ
Somerset County, NJ
20940.................... El Centro, CA...................... 0.8766
Imperial County, CA
21060.................... Elizabethtown, KY.................. 0.8388
Hardin County, KY
Larue County, KY
21140.................... Elkhart-Goshen, IN................. 0.9489
Elkhart County, IN
21300.................... Elmira, NY......................... 0.8341
Chemung County, NY
21340.................... El Paso, TX........................ 0.8541
El Paso County, TX
21500.................... Erie, PA........................... 0.8779
Erie County, PA
21660.................... Eugene-Springfield, OR............. 1.1034
Lane County, OR
21780.................... Evansville, IN-KY.................. 0.8522
Gibson County, IN
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820.................... Fairbanks, AK...................... 1.1114
Fairbanks North Star Borough, AK
21940.................... Fajardo, PR........................ 0.3790
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020.................... Fargo, ND-MN....................... 0.8172
Cass County, ND
Clay County, MN
22140.................... Farmington, NM..................... 0.7889
San Juan County, NM
22180.................... Fayetteville, NC................... 0.9358
Cumberland County, NC
Hoke County, NC
22220.................... Fayetteville-Springdale-Rogers, AR- 0.8775
MO.
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
22380.................... Flagstaff, AZ...................... 1.2475
Coconino County, AZ
22420.................... Flint, MI.......................... 1.1234
Genesee County, MI
22500.................... Florence, SC....................... 0.8114
Darlington County, SC
Florence County, SC
22520.................... Florence-Muscle Shoals, AL......... 0.7998
Colbert County, AL
Lauderdale County, AL
22540.................... Fond du Lac, WI.................... 0.9660
Fond du Lac County, WI
22660.................... Fort Collins-Loveland, CO.......... 1.0175
Larimer County, CO
22744.................... Fort Lauderdale-Pompano Beach- 1.0383
Deerfield Beach, FL.
Broward County, FL
22900.................... Fort Smith, AR-OK.................. 0.7861
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK
23020.................... Fort Walton Beach-Crestview-Destin, 0.8758
FL.
Okaloosa County, FL
23060.................... Fort Wayne, IN..................... 0.9012
Allen County, IN
[[Page 23134]]
Wells County, IN
Whitley County, IN
23104.................... Fort Worth-Arlington, TX........... 0.9499
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420.................... Fresno, CA......................... 1.1267
Fresno County, CA
23460.................... Gadsden, AL........................ 0.8266
Etowah County, AL
23540.................... Gainesville, FL.................... 0.8978
Alachua County, FL
Gilchrist County, FL
23580.................... Gainesville, GA.................... 0.9123
Hall County, GA
23844.................... Gary, IN........................... 0.9288
Jasper County, IN
Lake County, IN
Newton County, IN
Porter County, IN
24020.................... Glens Falls, NY.................... 0.8456
Warren County, NY
Washington County, NY
24140.................... Goldsboro, NC...................... 0.9056
Wayne County, NC
24220.................... Grand Forks, ND-MN................. 0.7775
Polk County, MN
Grand Forks County, ND
24300.................... Grand Junction, CO................. 0.9721
Mesa County, CO
24340.................... Grand Rapids-Wyoming, MI........... 0.9178
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500.................... Great Falls, MT.................... 0.8354
Cascade County, MT
24540.................... Greeley, CO........................ 0.9578
Weld County, CO
24580.................... Green Bay, WI...................... 0.9621
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660.................... Greensboro-High Point, NC.......... 0.9062
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780.................... Greenville, NC..................... 0.9401
Greene County, NC
Pitt County, NC
24860.................... Greenville-Mauldin-Easley, SC...... 0.9980
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020.................... Guayama, PR........................ 0.3537
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060.................... Gulfport-Biloxi, MS................ 0.8783
Hancock County, MS
Harrison County, MS
Stone County, MS
25180.................... Hagerstown-Martinsburg, MD-WV...... 0.8965
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260.................... Hanford-Corcoran, CA............... 1.1010
Kings County, CA
25420.................... Harrisburg-Carlisle, PA............ 0.9286
Cumberland County, PA
[[Page 23135]]
Dauphin County, PA
Perry County, PA
25500.................... Harrisonburg, VA................... 0.9025
Rockingham County, VA
Harrisonburg City, VA
25540.................... Hartford-West Hartford-East 1.1194
Hartford, CT.
Hartford County, CT
Middlesex County, CT
Tolland County, CT
25620.................... Hattiesburg, MS.................... 0.7664
Forrest County, MS
Lamar County, MS
Perry County, MS
25860.................... Hickory-Lenoir-Morganton, NC....... 0.9000
Alexander County, NC
Burke County, NC
Caldwell County, NC
Catawba County, NC
25980.................... Hinesville-Fort Stewart, GA \1\.... 0.9028
Liberty County, GA
Long County, GA
26100.................... Holland-Grand Haven, MI............ 0.8696
Ottawa County, MI
26180.................... Honolulu, HI....................... 1.1662
Honolulu County, HI
26300.................... Hot Springs, AR.................... 0.9004
Garland County, AR
26380.................... Houma-Bayou Cane-Thibodaux, LA..... 0.7875
Lafourche Parish, LA
Terrebonne Parish, LA
26420.................... Houston-Sugar Land-Baytown, TX..... 0.9841
Austin County, TX
Brazoria County, TX
Chambers County, TX
Fort Bend County, TX
Galveston County, TX
Harris County, TX
Liberty County, TX
Montgomery County, TX
San Jacinto County, TX
Waller County, TX
26580.................... Huntington-Ashland, WV-KY-OH....... 0.9097
Boyd County, KY
Greenup County, KY
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620.................... Huntsville, AL..................... 0.9064
Limestone County, AL
Madison County, AL
26820.................... Idaho Falls, ID.................... 0.9436
Bonneville County, ID
Jefferson County, ID
26900.................... Indianapolis-Carmel, IN............ 0.9742
Boone County, IN
Brown County, IN
Hamilton County, IN
Hancock County, IN
Hendricks County, IN
Johnson County, IN
Marion County, IN
Morgan County, IN
Putnam County, IN
Shelby County, IN
26980.................... Iowa City, IA...................... 0.9548
Johnson County, IA
Washington County, IA
27060.................... Ithaca, NY......................... 1.0112
Tompkins County, NY
27100.................... Jackson, MI........................ 0.8720
Jackson County, MI
[[Page 23136]]
27140.................... Jackson, MS........................ 0.8186
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180.................... Jackson, TN........................ 0.8581
Chester County, TN
Madison County, TN
27260.................... Jacksonville, FL................... 0.9105
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
27340.................... Jacksonville, NC................... 0.8026
Onslow County, NC
27500.................... Janesville, WI..................... 0.9201
Rock County, WI
27620.................... Jefferson City, MO................. 0.8709
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
27740.................... Johnson City, TN................... 0.7722
Carter County, TN
Unicoi County, TN
Washington County, TN
27780.................... Johnstown, PA...................... 0.8233
Cambria County, PA
27860.................... Jonesboro, AR...................... 0.7722
Craighead County, AR
Poinsett County, AR
27900.................... Joplin, MO......................... 0.8285
Jasper County, MO
Newton County, MO
28020.................... Kalamazoo-Portage, MI.............. 1.0264
Kalamazoo County, MI
Van Buren County, MI
28100.................... Kankakee-Bradley, IL............... 1.0174
Kankakee County, IL
28140.................... Kansas City, MO-KS................. 0.9679
Franklin County, KS
Johnson County, KS
Leavenworth County, KS
Linn County, KS
Miami County, KS
Wyandotte County, KS
Bates County, MO
Caldwell County, MO
Cass County, MO
Clay County, MO
Clinton County, MO
Jackson County, MO
Lafayette County, MO
Platte County, MO
Ray County, MO
28420.................... Kennewick-Pasco-Richland, WA....... 1.0448
Benton County, WA
Franklin County, WA
28660.................... Killeen-Temple-Fort Hood, TX....... 0.8702
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700.................... Kingsport-Bristol-Bristol, TN-VA... 0.7999
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740.................... Kingston, NY....................... 0.9367
[[Page 23137]]
Ulster County, NY
28940.................... Knoxville, TN...................... 0.7881
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020.................... Kokomo, IN......................... 0.9862
Howard County, IN
Tipton County, IN
29100.................... La Crosse, WI-MN................... 0.9915
Houston County, MN
La Crosse County, WI
29140.................... Lafayette, IN...................... 0.9181
Benton County, IN
Carroll County, IN
Tippecanoe County, IN
29180.................... Lafayette, LA...................... 0.8516
Lafayette Parish, LA
St. Martin Parish, LA
29340.................... Lake Charles, LA................... 0.7985
Calcasieu Parish, LA
Cameron Parish, LA
29404.................... Lake County-Kenosha County, IL-WI.. 1.0475
Lake County, IL
Kenosha County, WI
29420.................... Lake Havasu City-Kingman, AZ....... 1.0567
Mohave County, AZ
29460.................... Lakeland-Winter Haven, FL.......... 0.8390
Polk County, FL
29540.................... Lancaster, PA...................... 0.9204
Lancaster County, PA
29620.................... Lansing-East Lansing, MI........... 0.9770
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700.................... Laredo, TX......................... 0.8078
Webb County, TX
29740.................... Las Cruces, NM..................... 0.8939
Dona Ana County, NM
29820.................... Las Vegas-Paradise, NV............. 1.2130
Clark County, NV
29940.................... Lawrence, KS....................... 0.8580
Douglas County, KS
30020.................... Lawton, OK......................... 0.7847
Comanche County, OK
30140.................... Lebanon, PA........................ 0.8119
Lebanon County, PA
30300.................... Lewiston, ID-WA.................... 0.9570
Nez Perce County, ID
Asotin County, WA
30340.................... Lewiston-Auburn, ME................ 0.9085
Androscoggin County, ME
30460.................... Lexington-Fayette, KY.............. 0.8889
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY
Scott County, KY
Woodford County, KY
30620.................... Lima, OH........................... 0.9379
Allen County, OH
30700.................... Lincoln, NE........................ 0.9563
Lancaster County, NE
Seward County, NE
30780.................... Little Rock-North Little Rock- 0.8559
Conway, AR.
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
[[Page 23138]]
Saline County, AR
30860.................... Logan, UT-ID....................... 0.8993
Franklin County, ID
Cache County, UT
30980.................... Longview, TX....................... 0.8049
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020.................... Longview, WA....................... 1.0707
Cowlitz County, WA
31084.................... Los Angeles-Long Beach-Santa Ana, 1.2039
CA.
Los Angeles County, CA
31140.................... Louisville-Jefferson County, KY-IN. 0.8964
Clark County, IN
Floyd County, IN
Harrison County, IN
Washington County, IN
Bullitt County, KY
Henry County, KY
Meade County, KY
Nelson County, KY
Oldham County, KY
Shelby County, KY
Spencer County, KY
Trimble County, KY
31180.................... Lubbock, TX........................ 0.8751
Crosby County, TX
Lubbock County, TX
31340.................... Lynchburg, VA...................... 0.8521
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420.................... Macon, GA.......................... 0.9826
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460.................... Madera-Chowchilla, CA.............. 0.7958
Madera County, CA
31540.................... Madison, WI........................ 1.1234
Columbia County, WI
Dane County, WI
Iowa County, WI
31700.................... Manchester-Nashua, NH.............. 1.0171
Hillsborough County, NH
31740.................... Manhattan, KS...................... 0.7878
Geary County, KS
Pottawatomie County, KS
Riley County, KS
31860.................... Mankato-North Mankato, MN.......... 0.9177
Blue Earth County, MN
Nicollet County, MN
31900.................... Mansfield, OH...................... 0.9100
Richland County, OH
32420.................... Mayag[uuml]ez, PR.................. 0.3704
Hormigueros Municipio, PR
Mayag[uuml]ez Municipio, PR
32580.................... McAllen-Edinburg-Mission, TX....... 0.8852
Hidalgo County, TX
32780.................... Medford, OR........................ 1.0070
Jackson County, OR
32820.................... Memphis, TN-MS-AR.................. 0.9268
Crittenden County, AR
DeSoto County, MS
Marshall County, MS
Tate County, MS
Tunica County, MS
[[Page 23139]]
Fayette County, TN
Shelby County, TN
Tipton County, TN
32900.................... Merced, CA......................... 1.2123
Merced County, CA
33124.................... Miami-Miami Beach-Kendall, FL...... 0.9954
Miami-Dade County, FL
33140.................... Michigan City-La Porte, IN......... 0.9311
LaPorte County, IN
33260.................... Midland, TX........................ 0.9546
Midland County, TX
33340.................... Milwaukee-Waukesha-West Allis, WI.. 1.0151
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460.................... Minneapolis-St. Paul-Bloomington, 1.1095
MN-WI.
Anoka County, MN
Carver County, MN
Chisago County, MN
Dakota County, MN
Hennepin County, MN
Isanti County, MN
Ramsey County, MN
Scott County, MN
Sherburne County, MN
Washington County, MN
Wright County, MN
Pierce County, WI
St. Croix County, WI
33540.................... Missoula, MT....................... 0.9206
Missoula County, MT
33660.................... Mobile, AL......................... 0.7785
Mobile County, AL
33700.................... Modesto, CA........................ 1.2502
Stanislaus County, CA
33740.................... Monroe, LA......................... 0.7752
Ouachita Parish, LA
Union Parish, LA
33780.................... Monroe, MI......................... 0.8885
Monroe County, MI
33860.................... Montgomery, AL..................... 0.8304
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060.................... Morgantown, WV..................... 0.8459
Monongalia County, WV
Preston County, WV
34100.................... Morristown, TN..................... 0.7201
Grainger County, TN
Hamblen County, TN
Jefferson County, TN
34580.................... Mount Vernon-Anacortes, WA......... 1.0452
Skagit County, WA
34620.................... Muncie, IN......................... 0.8386
Delaware County, IN
34740.................... Muskegon-Norton Shores, MI......... 0.9823
Muskegon County, MI
34820.................... Myrtle Beach-North Myrtle Beach- 0.8730
Conway, SC.
Horry County, SC
34900.................... Napa, CA........................... 1.4453
Napa County, CA
34940.................... Naples-Marco Island, FL............ 0.9662
Collier County, FL
34980.................... Nashville-Davidson--Murfreesboro-- 0.9689
Franklin, TN.
Cannon County, TN
Cheatham County, TN
Davidson County, TN
Dickson County, TN
Hickman County, TN
[[Page 23140]]
Macon County, TN
Robertson County, TN
Rutherford County, TN
Smith County, TN
Sumner County, TN
Trousdale County, TN
Williamson County, TN
Wilson County, TN
35004.................... Nassau-Suffolk, NY................. 1.2477
Nassau County, NY
Suffolk County, NY
35084.................... Newark-Union, NJ-PA................ 1.1419
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
35300.................... New Haven-Milford, CT.............. 1.1545
New Haven County, CT
35380.................... New Orleans-Metairie-Kenner, LA.... 0.9092
Jefferson Parish, LA
Orleans Parish, LA
Plaquemines Parish, LA
St. Bernard Parish, LA
St. Charles Parish, LA
St. John the Baptist Parish, LA
St. Tammany Parish, LA
35644.................... New York-White Plains-Wayne, NY-NJ. 1.3005
Bergen County, NJ
Hudson County, NJ
Passaic County, NJ
Bronx County, NY
Kings County, NY
New York County, NY
Putnam County, NY
Queens County, NY
Richmond County, NY
Rockland County, NY
Westchester County, NY
35660.................... Niles-Benton Harbor, MI............ 0.8903
Berrien County, MI
35980.................... Norwich-New London, CT............. 1.1399
New London County, CT
36084.................... Oakland-Fremont-Hayward, CA........ 1.6404
Alameda County, CA
Contra Costa County, CA
36100.................... Ocala, FL.......................... 0.8556
Marion County, FL
36140.................... Ocean City, NJ..................... 1.0160
Cape May County, NJ
36220.................... Odessa, TX......................... 0.9862
Ector County, TX
36260.................... Ogden-Clearfield, UT............... 0.9361
Davis County, UT
Morgan County, UT
Weber County, UT
36420.................... Oklahoma City, OK.................. 0.8900
Canadian County, OK
Cleveland County, OK
Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500.................... Olympia, WA........................ 1.1531
Thurston County, WA
36540.................... Omaha-Council Bluffs, NE-IA........ 0.9608
Harrison County, IA
Mills County, IA
Pottawattamie County, IA
[[Page 23141]]
Cass County, NE
Douglas County, NE
Sarpy County, NE
Saunders County, NE
Washington County, NE
36740.................... Orlando-Kissimmee, FL.............. 0.8951
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780.................... Oshkosh-Neenah, WI................. 0.9152
Winnebago County, WI
36980.................... Owensboro, KY...................... 0.8357
Daviess County, KY
Hancock County, KY
McLean County, KY
37100.................... Oxnard-Thousand Oaks-Ventura, CA... 1.2301
Ventura County, CA
37340.................... Palm Bay-Melbourne-Titusville, FL.. 0.9060
Brevard County, FL
37380.................... Palm Coast, FL..................... 0.9603
Flagler County, FL
37460.................... Panama City-Lynn Haven-Panama City 0.8324
Beach, FL.
Bay County, FL
37620.................... Parkersburg-Marietta-Vienna, WV-OH. 0.7716
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700.................... Pascagoula, MS..................... 0.8433
George County, MS
Jackson County, MS
37764.................... Peabody, MA........................ 1.0871
Essex County, MA
37860.................... Pensacola-Ferry Pass-Brent, FL..... 0.8312
Escambia County, FL
Santa Rosa County, FL
37900.................... Peoria, IL......................... 0.9155
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964.................... Philadelphia, PA................... 1.0739
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060.................... Phoenix-Mesa-Scottsdale, AZ........ 1.0630
Maricopa County, AZ
Pinal County, AZ
38220.................... Pine Bluff, AR..................... 0.7281
Cleveland County, AR
Jefferson County, AR
Lincoln County, AR
38300.................... Pittsburgh, PA..................... 0.8625
Allegheny County, PA
Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340.................... Pittsfield, MA..................... 1.0658
Berkshire County, MA
38540.................... Pocatello, ID...................... 0.9239
Bannock County, ID
Power County, ID
38660.................... Ponce, PR.......................... 0.4220
Juana D[iacute]az Municipio, PR
[[Page 23142]]
Ponce Municipio, PR
Villalba Municipio, PR
38860.................... Portland-South Portland-Biddeford, 1.0187
ME.
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900.................... Portland-Vancouver-Beaverton, OR-WA 1.1498
Clackamas County, OR
Columbia County, OR
Multnomah County, OR
Washington County, OR
Yamhill County, OR
Clark County, WA
Skamania County, WA
38940.................... Port St. Lucie, FL................. 0.9896
Martin County, FL
St. Lucie County, FL
39100.................... Poughkeepsie-Newburgh-Middletown, 1.1216
NY.
Dutchess County, NY
Orange County, NY
39140.................... Prescott, AZ....................... 1.0121
Yavapai County, AZ
39300.................... Providence-New Bedford-Fall River, 1.0782
RI-MA.
Bristol County, MA
Bristol County, RI
Kent County, RI
Newport County, RI
Providence County, RI
Washington County, RI
39340.................... Provo-Orem, UT..................... 0.9548
Juab County, UT
Utah County, UT
39380.................... Pueblo, CO......................... 0.8570
Pueblo County, CO
39460.................... Punta Gorda, FL.................... 0.8774
Charlotte County, FL
39540.................... Racine, WI......................... 0.9373
Racine County, WI
39580.................... Raleigh-Cary, NC................... 0.9663
Franklin County, NC
Johnston County, NC
Wake County, NC
39660.................... Rapid City, SD..................... 1.0046
Meade County, SD
Pennington County, SD
39740.................... Reading, PA........................ 0.9263
Berks County, PA
39820.................... Redding, CA........................ 1.4039
Shasta County, CA
39900.................... Reno-Sparks, NV.................... 1.0285
Storey County, NV
Washoe County, NV
40060.................... Richmond, VA....................... 0.9521
Amelia County, VA
Caroline County, VA
Charles City County, VA
Chesterfield County, VA
Cumberland County, VA
Dinwiddie County, VA
Goochland County, VA
Hanover County, VA
Henrico County, VA
King and Queen County, VA
King William County, VA
Louisa County, VA
New Kent County, VA
Powhatan County, VA
Prince George County, VA
Sussex County, VA
Colonial Heights City, VA
Hopewell City, VA
[[Page 23143]]
Petersburg City, VA
Richmond City, VA
40140.................... Riverside-San Bernardino-Ontario, 1.1285
CA.
Riverside County, CA
San Bernardino County, CA
40220.................... Roanoke, VA........................ 0.8671
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340.................... Rochester, MN...................... 1.1136
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380.................... Rochester, NY...................... 0.8724
Livingston County, NY
Monroe County, NY
Ontario County, NY
Orleans County, NY
Wayne County, NY
40420.................... Rockford, IL....................... 1.0152
Boone County, IL
Winnebago County, IL
40484.................... Rockingham County, NH.............. 1.0125
Rockingham County, NH
Strafford County, NH
40580.................... Rocky Mount, NC.................... 0.8845
Edgecombe County, NC
Nash County, NC
40660.................... Rome, GA........................... 0.8915
Floyd County, GA
40900.................... Sacramento--Arden-Arcade-- 1.4073
Roseville, CA.
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980.................... Saginaw-Saginaw Township North, MI. 0.9122
Saginaw County, MI
41060.................... St. Cloud, MN...................... 1.1107
Benton County, MN
Stearns County, MN
41100.................... St. George, UT..................... 0.9236
Washington County, UT
41140.................... St. Joseph, MO-KS.................. 1.0189
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180.................... St. Louis, MO-IL................... 0.9102
Bond County, IL
Calhoun County, IL
Clinton County, IL
Jersey County, IL
Macoupin County, IL
Madison County, IL
Monroe County, IL
St. Clair County, IL
Crawford County, MO
Franklin County, MO
Jefferson County, MO
Lincoln County, MO
St. Charles County, MO
St. Louis County, MO
Warren County, MO
Washington County, MO
St. Louis City, MO
41420.................... Salem, OR.......................... 1.0974
Marion County, OR
Polk County, OR
[[Page 23144]]
41500.................... Salinas, CA........................ 1.5207
Monterey County, CA
41540.................... Salisbury, MD...................... 0.9110
Somerset County, MD
Wicomico County, MD
41620.................... Salt Lake City, UT................. 0.9378
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660.................... San Angelo, TX..................... 0.7914
Irion County, TX
Tom Green County, TX
41700.................... San Antonio, TX.................... 0.8857
Atascosa County, TX
Bandera County, TX
Bexar County, TX
Comal County, TX
Guadalupe County, TX
Kendall County, TX
Medina County, TX
Wilson County, TX
41740.................... San Diego-Carlsbad-San Marcos, CA.. 1.1752
San Diego County, CA
41780.................... Sandusky, OH....................... 0.8888
Erie County, OH
41884.................... San Francisco-San Mateo-Redwood 1.5874
City, CA.
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900.................... San Germ[aacute]n-Cabo Rojo, PR.... 0.4740
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio, PR
San Germ[aacute]n Municipio, PR
41940.................... San Jose-Sunnyvale-Santa Clara, CA. 1.6404
San Benito County, CA
Santa Clara County, CA
41980.................... San Juan-Caguas-Guaynabo, PR....... 0.4363
Aguas Buenas Municipio, PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio, PR
Bayam[oacute]n Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Can[oacute]vanas Municipio, PR
Carolina Municipio, PR
Cata[ntilde]o Municipio, PR
Cayey Municipio, PR
Ciales Municipio, PR
Cidra Municipio, PR
Comer[iacute]o Municipio, PR
Corozal Municipio, PR
Dorado Municipio, PR
Florida Municipio, PR
Guaynabo Municipio, PR
Gurabo Municipio, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Lo[iacute]za Municipio, PR
Manat[iacute] Municipio, PR
Maunabo Municipio, PR
Morovis Municipio, PR
Naguabo Municipio, PR
Naranjito Municipio, PR
Orocovis Municipio, PR
Quebradillas Municipio, PR
R[iacute]o Grande Municipio, PR
[[Page 23145]]
San Juan Municipio, PR
San Lorenzo Municipio, PR
Toa Alta Municipio, PR
Toa Baja Municipio, PR
Trujillo Alto Municipio, PR
Vega Alta Municipio, PR
Vega Baja Municipio, PR
Yabucoa Municipio, PR
42020.................... San Luis Obispo-Paso Robles, CA.... 1.2550
San Luis Obispo County, CA
42044.................... Santa Ana-Anaheim-Irvine, CA....... 1.1972
Orange County, CA
42060.................... Santa Barbara-Santa Maria-Goleta, 1.2213
CA.
Santa Barbara County, CA
42100.................... Santa Cruz-Watsonville, CA......... 1.6735
Santa Cruz County, CA
42140.................... Santa Fe, NM....................... 1.0694
Santa Fe County, NM
42220.................... Santa Rosa-Petaluma, CA............ 1.5891
Sonoma County, CA
42340.................... Savannah, GA....................... 0.9043
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540.................... Scranton--Wilkes-Barre, PA......... 0.8375
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644.................... Seattle-Bellevue-Everett, WA....... 1.1577
King County, WA
Snohomish County, WA
42680.................... Sebastian-Vero Beach, FL........... 0.9362
Indian River County, FL
43100.................... Sheboygan, WI...................... 0.9166
Sheboygan County, WI
43300.................... Sherman-Denison, TX................ 0.8064
Grayson County, TX
43340.................... Shreveport-Bossier City, LA........ 0.8383
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580.................... Sioux City, IA-NE-SD............... 0.9094
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620.................... Sioux Falls, SD.................... 0.8983
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780.................... South Bend-Mishawaka, IN-MI........ 0.9690
St. Joseph County, IN
Cass County, MI
43900.................... Spartanburg, SC.................... 0.9341
Spartanburg County, SC
44060.................... Spokane, WA........................ 1.0444
Spokane County, WA
44100.................... Springfield, IL.................... 0.9545
Menard County, IL
Sangamon County, IL
44140.................... Springfield, MA.................... 1.0373
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180.................... Springfield, MO.................... 0.8453
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
[[Page 23146]]
44220.................... Springfield, OH.................... 0.9195
Clark County, OH
44300.................... State College, PA.................. 0.9096
Centre County, PA
44700.................... Stockton, CA....................... 1.2331
San Joaquin County, CA
44940.................... Sumter, SC......................... 0.8152
Sumter County, SC
45060.................... Syracuse, NY....................... 0.9785
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104.................... Tacoma, WA......................... 1.1195
Pierce County, WA
45220.................... Tallahassee, FL.................... 0.8406
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
45300.................... Tampa-St. Petersburg-Clearwater, FL 0.8982
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460.................... Terre Haute, IN.................... 0.9061
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500.................... Texarkana, TX--Texarkana, AR....... 0.8113
Miller County, AR
Bowie County, TX
45780.................... Toledo, OH......................... 0.9541
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820.................... Topeka, KS......................... 0.9026
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940.................... Trenton-Ewing, NJ.................. 1.0552
Mercer County, NJ
46060.................... Tucson, AZ......................... 0.9505
Pima County, AZ
46140.................... Tulsa, OK.......................... 0.8662
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK
Rogers County, OK
Tulsa County, OK
Wagoner County, OK
46220.................... Tuscaloosa, AL..................... 0.8698
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340.................... Tyler, TX.......................... 0.8312
Smith County, TX
46540.................... Utica-Rome, NY..................... 0.8460
Herkimer County, NY
Oneida County, NY
46660.................... Valdosta, GA....................... 0.7944
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700.................... Vallejo-Fairfield, CA.............. 1.4934
Solano County, CA
[[Page 23147]]
47020.................... Victoria, TX....................... 0.8054
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220.................... Vineland-Millville-Bridgeton, NJ... 1.0207
Cumberland County, NJ
47260.................... Virginia Beach-Norfolk-Newport 0.8960
News, VA-NC.
Currituck County, NC
Gloucester County, VA
Isle of Wight County, VA
James City County, VA
Mathews County, VA
Surry County, VA
York County, VA
Chesapeake City, VA
Hampton City, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
47300.................... Visalia-Porterville, CA............ 1.0221
Tulare County, CA
47380.................... Waco, TX........................... 0.8377
McLennan County, TX
47580.................... Warner Robins, GA.................. 0.8754
Houston County, GA
47644.................... Warren-Troy-Farmington Hills, MI... 0.9806
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894.................... Washington-Arlington-Alexandria, DC- 1.0882
VA-MD-WV.
District of Columbia, DC
Calvert County, MD
Charles County, MD
Prince George's County, MD
Arlington County, VA
Clarke County, VA
Fairfax County, VA
Fauquier County, VA
Loudoun County, VA
Prince William County, VA
Spotsylvania County, VA
Stafford County, VA
Warren County, VA
Alexandria City, VA
Fairfax City, VA
Falls Church City, VA
Fredericksburg City, VA
Manassas City, VA
Manassas Park City, VA
Jefferson County, WV
47940.................... Waterloo-Cedar Falls, IA........... 0.8518
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140.................... Wausau, WI......................... 0.9440
Marathon County, WI
48260.................... Weirton-Steubenville, WV-OH........ 0.7368
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300.................... Wenatchee-East Wenatchee, WA....... 0.9719
Chelan County, WA
Douglas County, WA
48424.................... West Palm Beach-Boca Raton-Boynton 0.9879
Beach, FL.
Palm Beach County, FL
[[Page 23148]]
48540.................... Wheeling, WV-OH.................... 0.6869
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620.................... Wichita, KS........................ 0.9018
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660.................... Wichita Falls, TX.................. 0.9197
Archer County, TX
Clay County, TX
Wichita County, TX
48700.................... Williamsport, PA................... 0.7877
Lycoming County, PA
48864.................... Wilmington, DE-MD-NJ............... 1.0555
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900.................... Wilmington, NC..................... 0.8986
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020.................... Winchester, VA-WV.................. 0.9777
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180.................... Winston-Salem, NC.................. 0.8953
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340.................... Worcester, MA...................... 1.1089
Worcester County, MA
49420.................... Yakima, WA......................... 0.9949
Yakima County, WA
49500.................... Yauco, PR.......................... 0.3348
Gu[aacute]nica Municipio, PR
Guayanilla Municipio, PR
Pe[ntilde]uelas Municipio, PR
Yauco Municipio, PR
49620.................... York-Hanover, PA................... 0.9299
York County, PA
49660.................... Youngstown-Warren-Boardman, OH-PA.. 0.8679
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700.................... Yuba City, CA...................... 1.1265
Sutter County, CA
Yuba County, CA
49740.................... Yuma, AZ........................... 0.9143
Yuma County, AZ
------------------------------------------------------------------------
\1\ At this time, there are no hospitals located in this urban area on
which to base a wage index.
Table 2--RY 2011 Wage Index Based on CBSA Labor Market Areas for Rural
Areas
------------------------------------------------------------------------
State code Nonurban area Wage index
------------------------------------------------------------------------
1......................... Alabama........................ 0.7327
2......................... Alaska......................... 1.1669
3......................... Arizona........................ 0.8790
4......................... Arkansas....................... 0.7332
5......................... California..................... 1.2051
6......................... Colorado....................... 0.9929
7......................... Connecticut.................... 1.1093
8......................... Delaware....................... 0.9910
10........................ Florida........................ 0.8566
11........................ Georgia........................ 0.7623
12........................ Hawaii......................... 1.1113
13........................ Idaho.......................... 0.7733
14........................ Illinois....................... 0.8312
15........................ Indiana........................ 0.8529
16........................ Iowa........................... 0.8624
17........................ Kansas......................... 0.8167
18........................ Kentucky....................... 0.7813
19........................ Louisiana...................... 0.7611
20........................ Maine.......................... 0.8579
21........................ Maryland....................... 0.9131
22........................ Massachusetts \1\.............. 1.1700
23........................ Michigan....................... 0.8778
[[Page 23149]]
24........................ Minnesota...................... 0.9160
25........................ Mississippi.................... 0.7638
26........................ Missouri....................... 0.7671
27........................ Montana........................ 0.8399
28........................ Nebraska....................... 0.8705
29........................ Nevada......................... 0.9674
30........................ New Hampshire.................. 0.9957
31........................ New Jersey \1\................. ...........
32........................ New Mexico..................... 0.8938
33........................ New York....................... 0.8269
34........................ North Carolina................. 0.8535
35........................ North Dakota................... 0.7813
36........................ Ohio........................... 0.8506
37........................ Oklahoma....................... 0.7654
38........................ Oregon......................... 1.0236
39........................ Pennsylvania................... 0.8306
40........................ Puerto Rico \1\................ 0.4047
41........................ Rhode Island \1\............... ...........
42........................ South Carolina................. 0.8394
43........................ South Dakota................... 0.8510
44........................ Tennessee...................... 0.7808
45........................ Texas.......................... 0.7759
46........................ Utah........................... 0.8363
47........................ Vermont........................ 0.9763
48........................ Virgin Islands................. 0.7416
49........................ Virginia....................... 0.7869
50........................ Washington..................... 1.0224
51........................ West Virginia.................. 0.7396
52........................ Wisconsin...................... 0.9206
53........................ Wyoming........................ 0.9535
65........................ Guam........................... 0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
exception of Massachusetts and Puerto Rico. Massachusetts and Puerto
Rico have areas designated as rural; however, no short-term, acute
care hospitals are located in the area(s) for FY 2010. The rural
Massachusetts wage index is calculated as the average of all
contiguous CBSAs. The Puerto Rico wage index is the same as FY 2009.
[FR Doc. 2010-9870 Filed 4-29-10; 8:45 am]
BILLING CODE 4120-01-P