[Federal Register Volume 61, Number 106 (Friday, May 31, 1996)]
[Proposed Rules]
[Pages 27444-27708]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-13613]
[[Page 27443]]
_______________________________________________________________________
Part II
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
42 CFR Part 412, et al.
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal year 1997 Rates; Proposed Rule
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed
Rules
[[Page 27444]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 412, 413, and 489
[BPD-847-P]
RIN 0938-AH34
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 1997 Rates
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
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SUMMARY: We are proposing to revise the Medicare hospital inpatient
prospective payment systems for operating costs and capital-related
costs to implement necessary changes arising from our continuing
experience with the systems. In addition, in the addendum to this
proposed rule, we are describing proposed changes in the amounts and
factors necessary to determine prospective payment rates for Medicare
hospital inpatient services for operating costs and capital-related
costs. These changes would be applicable to discharges occurring on or
after October 1, 1996. We are also setting forth proposed rate-of-
increase limits as well as proposing changes for hospitals and hospital
units excluded from the prospective payment systems.
DATES: Comments will be considered if received at the appropriate
address, as provided below, no later than 5 p.m. on July 31, 1996.
ADDRESSES: Mail written comments (an original and 3 copies) to the
following address:
Health Care Financing Administration, Department of Health and Human
Services, Attention: BPD-847-P, P.O. Box 7517, Baltimore, MD 21207-
0517.
If you prefer, you may deliver your written comments (an original
and 3 copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-09-26, Central Building, 7500 Security Boulevard, Baltimore, MD
21244-1850.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-847-P. Comments received timely will be available for
public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in Room 309-G of
the Department's offices at 200 Independence Avenue, SW., Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(phone: (202) 690-7890).
For comments that relate to information collection requirements,
mail a copy of comments to: Office of Information and Regulatory
Affairs, Office of Management and Budget, Room 10235, New Executive
Office Building, Washington, DC 20503, Attn: Allison Herron Eydt, HCFA
Desk Officer.
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $8.00. As an alternative, you can view
and photocopy the Federal Register document at most libraries
designated as Federal Depository Libraries and at many other public and
academic libraries throughout the country that receive the Federal
Register.
FOR FURTHER INFORMATION CONTACT:
Nancy Edwards (410) 786-4531, Operating Prospective Payment, DRG, Wage
Index Issues.
Tzvi Hefter (410) 786-4529, Capital Prospective Payment, Excluded
Hospitals.
SUPPLEMENTARY INFORMATION:
I. Background
A. Summary
Under section 1886(d) of the Social Security Act (the Act), a
system of payment for the operating costs of acute care hospital
inpatient stays under Medicare Part A (Hospital Insurance) based on
prospectively-set rates was established effective with hospital cost
reporting periods beginning on or after October 1, 1983. Under this
system, Medicare payment for hospital inpatient operating costs is made
at a predetermined, specific rate for each hospital discharge. All
discharges are classified according to a list of diagnosis-related
groups (DRGs). The regulations governing the hospital inpatient
prospective payment system are located in 42 CFR part 412. On September
1, 1995, we published a final rule with comment period (60 FR 45778) to
implement changes to the prospective payment system for hospital
operating costs beginning with Federal fiscal year (FY) 1996.
For cost reporting periods beginning before October 1, 1991,
hospital inpatient operating costs were the only costs covered under
the prospective payment system. Payment for capital-related costs had
been made on a reasonable cost basis because, under sections 1886(a)(4)
and (d)(1)(A) of the Act, those costs had been specifically excluded
from the definition of inpatient operating costs. However, section
4006(b) of the Omnibus Budget Reconciliation Act of 1987 (Public Law
100-203) revised section 1886(g)(1) of the Act to require that, for
hospitals paid under the prospective payment system for operating
costs, capital-related costs would also be paid under a prospective
payment system effective with cost reporting periods beginning on or
after October 1, 1991. As required by section 1886(g) of the Act, we
replaced the reasonable cost-based payment methodology with a
prospective payment methodology for hospital inpatient capital-related
costs. Under the new methodology, effective for cost reporting periods
beginning on or after October 1, 1991, a predetermined payment amount
per discharge is made for Medicare inpatient capital-related costs.
(See subpart M of 42 CFR part 412, and the August 30, 1991 final rule
(56 FR 43358) for a complete discussion of the prospective payment
system for hospital inpatient capital-related costs.)
B. Major Contents of This Proposed Rule
In this proposed rule, we are setting forth proposed changes to the
Medicare hospital inpatient prospective payment systems for both
operating costs and capital-related costs. This proposed rule would be
effective for discharges occurring on or after October 1, 1996.
Following is a summary of the major changes that we are proposing to
make:
1. Changes to the DRG Classifications and Relative Weights
As required by section 1886(d)(4)(C) of the Act, we must adjust the
DRG classifications and relative weights at least annually. Our
proposed changes for FY 1997 are set forth in section II of this
preamble.
2. Changes to the Hospital Wage Index
In section III of this preamble, we discuss revisions to the wage
index and the annual update of the wage data. Specific issues addressed
in this section include:
FY 1997 wage index update.
[[Page 27445]]
Revisions to the wage index based on hospital
redesignations.
Solicitation of public comment on possible changes to the
following:
--Contract labor--expansion of allowable costs.
--Revision in Puerto Rico labor market areas.
Medicare Geographic Classification Review Board--
composition and criteria.
3. Rebasing and Revision of the Hospital Market Baskets
In section IV of this preamble, we discuss our proposal to use a
rebased and revised hospital market basket in developing the FY 1997
update factor for the operating prospective payment rates, the capital
prospective payment rates, and the excluded hospital rate-of-increase
limits.
4. Other Changes to the Prospective Payment System for Inpatient
Operating Costs
In section V of this preamble, we discuss several provisions of the
regulations in 42 CFR parts 412, 413, and 489 and set forth certain
proposed changes concerning the following:
Sole community hospitals.
Rural referral centers.
Disproportionate share adjustment.
Direct graduate medical education programs.
Hospital distribution of ``An Important Message from
Medicare.''
5. Changes and Clarifications to the Prospective Payment System for
Capital-Related Costs
In section VI of this preamble, we discuss several provisions of
the regulations in 42 CFR part 412 and set forth certain proposed
changes concerning the following:
Use of simplified cost accounting.
The capital Federal and hospital-specific rates.
6. Changes for Hospitals and Hospital Units Excluded From the
Prospective Payment Systems
In section VII of this preamble, we discuss a clarification
concerning the calculation of payments to hospitals excluded from the
prospective payment system.
7. Determining Prospective Payment Operating and Capital Rates and
Rate-of-Increase Limits
In the addendum to this proposed rule, we set forth proposed
changes to the amounts and factors for determining the FY 1997
prospective payment rates for operating costs and capital-related
costs. We are also proposing update factors for determining the rate-
of-increase limits for cost reporting periods beginning in FY 1997 for
hospitals and hospital units excluded from the prospective payment
system. In addition, we have included a detailed discussion of our
methodology for setting thresholds for outlier cases. We are inviting
comments on our methodology and any suggestions for changes in that
methodology that could help us better predict outlier payments.
8. Impact Analysis
In Appendix A, we set forth an analysis of the impact that the
proposed changes described in this rule would have on affected
entities.
9. Capital Acquisition Model
Appendix B contains the technical appendix on the proposed FY 1997
capital acquisition model.
10. Rebased Market Basket Data Sources
Appendix C sets forth the data sources used to determine the market
basket relative weights and choice of price proxies.
11. Report to Congress on the Update Factor for Prospective Payment
Hospitals and Hospitals Excluded From the Prospective Payment System
Section 1886(e)(3)(B) of the Act requires that the Secretary report
to Congress on our initial estimate of an update factor for FY 1997 for
both hospitals included in and hospitals excluded from the prospective
payment systems. This report is included as Appendix D to this proposed
rule.
12. Proposed Recommendation of Update Factor for Hospital Inpatient
Operating Costs
As required by sections 1886(e)(4) and (e)(5) of the Act, Appendix
E provides our recommendation of the appropriate percentage change for
FY 1997 for the following:
Large urban area and other area average standardized
amounts (and hospital-specific rates applicable to sole community
hospitals) for hospital inpatient services paid for under the
prospective payment system for operating costs.
Target rate-of-increase limits to the allowable operating
costs of hospital inpatient services furnished by hospitals and
hospital units excluded from the prospective payment system.
13. Discussion of Prospective Payment Assessment Commission
Recommendations
The Prospective Payment Assessment Commission (ProPAC) is directed
by section 1886(e)(2)(A) of the Act to make recommendations on the
appropriate percentage change factor to be used in updating the average
standardized amounts. In addition, section 1886(e)(2)(B) of the Act
directs ProPAC to make recommendations regarding changes in each of the
Medicare payment policies under which payments to an institution are
prospectively determined. In particular, the recommendations relating
to the hospital inpatient prospective payment systems are to include
recommendations concerning the number of DRGs used to classify
patients, adjustments to the DRGs to reflect severity of illness, and
changes in the methods under which hospitals are paid for capital-
related costs. Under section 1886(e)(3)(A) of the Act, the
recommendations required of ProPAC under sections 1886(e)(2)(A) and (B)
of the Act are to be reported to Congress not later than March 1 of
each year.
We are printing ProPAC's March 1, 1996 report, which includes its
recommendations, as Appendix F of this document. The recommendations,
and the actions we are proposing to take with regard to them (when an
action is recommended), are discussed in detail in the appropriate
sections of this preamble, the addendum, or the appendices to this
proposed rule. See section VIII of this preamble for specific
information concerning where individual recommendations are addressed.
For a brief summary of the ProPAC recommendations, we refer the reader
to the beginning of the ProPAC report as set forth in Appendix F of
this proposed rule. For further information relating specifically to
the ProPAC report, contact ProPAC at (202) 401-8986.
II. Proposed Changes to DRG Classifications and Relative Weights
A. Background
Under the prospective payment system, we pay for inpatient hospital
services on the basis of a rate per discharge that varies by the DRG to
which a beneficiary's stay is assigned. The formula used to calculate
payment for a specific case takes an individual hospital's payment rate
per case and multiplies it by the weight of the DRG to which the case
is assigned. Each DRG weight represents the average resources required
to care for cases in that particular DRG relative to the average
resources used to treat cases in all DRGs.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account
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for changes in resource consumption. Accordingly, section 1886(d)(4)(C)
of the Act requires that the Secretary adjust the DRG classifications
and relative weights annually. These adjustments are made to reflect
changes in treatment patterns, technology, and any other factors that
may change the relative use of hospital resources. The proposed changes
to the DRG classification system and the proposed recalibration of the
DRG weights for discharges occurring on or after October 1, 1996 are
discussed below.
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the prospective
payment system based on the principal diagnosis, up to eight additional
diagnoses, and up to six procedures performed during the stay, as well
as age, sex, and discharge status of the patient. The diagnosis and
procedure information is reported by the hospital using codes from the
International Classification of Diseases, Ninth Edition, Clinical
Modification (ICD-9-CM). The Medicare fiscal intermediary enters the
information into its claims system and subjects it to a series of
automated screens called the Medicare Code Editor (MCE). These screens
are designed to identify cases that require further review before
classification into a DRG can be accomplished.
After screening through the MCE and any further development of the
claims, cases are classified by the GROUPER software program into the
appropriate DRG. The GROUPER program was developed as a means of
classifying each case into a DRG on the basis of the diagnosis and
procedure codes and demographic information (that is, sex, age, and
discharge status). It is used both to classify past cases in order to
measure relative hospital resource consumption to establish the DRG
weights and to classify current cases for purposes of determining
payment. The records for all Medicare hospital inpatient discharges are
maintained in the Medicare Provider Analysis and Review (MedPAR) file.
The data in this file are used to evaluate possible DRG classification
changes and to recalibrate the DRG weights.
Currently, cases are assigned to one of 492 DRGs in 25 major
diagnostic categories (MDCs). Most MDCs are based on a particular organ
system of the body (for example, MDC 6, Diseases and Disorders of the
Digestive System); however, some MDCs are not constructed on this basis
since they involve multiple organ systems (for example, MDC 22, Burns).
In general, principal diagnosis determines MDC assignment. However,
there are five DRGs to which cases are assigned on the basis of
procedure codes rather than first assigning them to an MDC based on the
principal diagnosis. These are the DRGs for liver, bone marrow, and
lung transplant (DRGs 480, 481, and 495, respectively) and the two DRGs
for tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs
before classification to an MDC.
Within most MDCs, cases are then divided into surgical DRGs (based
on a surgical hierarchy that orders individual procedures or groups of
procedures by resource intensity) and medical DRGs. Medical DRGs
generally are differentiated on the basis of diagnosis and age. Some
surgical and medical DRGs are further differentiated based on the
presence or absence of complications or comorbidities (hereafter CC).
Generally, GROUPER does not consider other procedures; that is,
nonsurgical procedures or minor surgical procedures generally not
performed in an operating room are not listed as operating room (OR)
procedures in the GROUPER decision tables. However, there are a few
non-OR procedures that do affect DRG assignment for certain principal
diagnoses, such as extracorporeal shock wave lithotripsy for patients
with a principal diagnosis of urinary stones.
The changes we are proposing to make to the DRG classification
system for FY 1997 and other decisions concerning DRGs are set forth
below.
2. Pre-MDC DRGs
Effective October 1, 1994, ICD-9-CM procedure code 41.04,
Autologous hematopoietic stem cell transplant, was created to capture
the transplantation of stem cells obtained from bone marrow or
peripheral blood. At that time, we designated the code as non-OR. This
transplant procedure was previously assigned to procedure code 99.73,
Therapeutic erythrocytapheresis, which is designated as a non-OR
procedure. When we created this code, we received comments requesting
that it be designated as an OR procedure and assigned to DRG 481 (Bone
Marrow Transplant) based on the resource use associated with the type
of transplant. However, as we stated in the September 1, 1994 final
rule (59 FR 45340), when a new code is introduced, our longstanding
practice is to assign it to the same DRG category as its predecessor
code. One compelling reason for this practice is our inability to move
the cases associated with a new code to a new DRG assignment as part of
DRG reclassification and recalibration. Because we could not separately
identify the stem cell transplant cases from the other cases coded with
99.73 in order to reclassify them and their charges to a new DRG, we
were unable to predict the new weights of both the DRGs in which this
code currently is classified and the new DRG to which it would be
assigned. Therefore, we were prevented from redesignating code 41.04 as
an OR procedure or assigning it to a DRG. However, we stated that we
would analyze the stem cell cases as soon as the FY 1995 cases were
available.
This year, the FY 1995 Medicare Provider Analysis and Review
(MedPAR) file is available for use in DRG analysis and weight setting
for FY 1997. In the December 1995 update to the FY 1995 MedPAR file,
there are a total of 178 cases reporting the performance of a stem cell
transplant. Of that number, 13 cases also reported the performance of a
bone marrow transplant. Those cases were removed from our analysis
because they are already classified to DRG 481. Of the remaining 165
cases, 100 cases did not meet the coverage criteria for Medicare
payment. As set forth in the Medicare Coverage Issues Manual at section
35-30.1 (see Transmittal No. 84, April 1996), autologous stem cell
transplants are not covered when performed for the following
conditions:
Acute leukemia not in remission (diagnosis codes 204.00,
205.00, 206.00, 207.00, and 208.00).
Chronic granulocytic leukemia (diagnosis codes 205.10 and
205.11).
Solid tumors (other than neuroblastomas) (diagnosis codes
140.0 through 199.1)
Multiple myeloma (diagnosis codes 203.00, 203.01 and
238.6).
After eliminating the noncovered cases, 65 cases of stem cell
transplant remained. The average standardized charge for these cases
was approximately $83,000. The average standardized charge for bone
marrow transplant cases in the FY 1995 MedPAR file is approximately
$98,000. Thus, since the average resource use associated with stem cell
transplant is similar to that associated with bone marrow transplant,
we are proposing to assign procedure code 41.04 to DRG 481 effective
with discharges occurring on or after October 1, 1996. The overall
average charge for stem cell and bone marrow combined is just under
$93,000. In addition, we propose to designate stem cell transplant as
an OR procedure.
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3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Sleep Apnea
We have received correspondence requesting that we review the DRG
assignment of cases in which surgery is performed to correct
obstructive sleep apnea (diagnosis code 780.57). When coded as a
principal diagnosis, sleep apnea is assigned to DRGs 34 and 35 (Other
Disorders of the Nervous System)\1\ in MDC 1.
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\1\ A single title combined with two DRG numbers is used to
signify pairs. Generally, the first DRG is for cases with CC and the
second DRG is for cases without CC. If a third number is included,
it represents cases of patients who are age 0-17. Occasionally, a
pair of DRGs is split on age>17 and age 0-17.
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Recently, new surgical interventions to correct sleep apnea have
been introduced. The procedures most frequently performed for this
condition are the following:
Code and Description
27.69 Other plastic repair of palate
29.4 Plastic operation on pharynx
29.59 Other repair of pharynx
Since none of these surgical procedures is assigned to MDC 1, cases
of sleep apnea treated with one of these surgeries are assigned to DRG
468 (Extensive OR Procedure Unrelated to Principal Diagnosis) in the
case of codes 25.59 and 78.49 or to DRG 477 (Nonextensive OR Procedure
Unrelated to Principal Diagnosis) in the case of code 29.4.
We are proposing to address this situation by assigning the three
surgical procedures to MDC 1. Based on the charges associated with
these cases and the fact that they are not clinically similar to the
other surgical DRGs in MDC 1, we are proposing to include them in DRGs
7 and 8 (Peripheral and Cranial Nerve and Other Nervous System
Procedures).
b. Guillain-Barre Syndrome
Guillain-Barre syndrome (diagnosis code 357.0) is a post-infectious
polyneuropathy in which severely affected patients may require
ventilatory assistance and long stays in intensive care. In recognition
of the high resource consumption associated with this diagnosis,
effective with FY 1991, we reassigned code 357.0 from DRGs 18 and 19
(Cranial and Peripheral Nerve Disorders) to DRG 20 (Nervous System
Infection Except Viral Meningitis). (See the September 4, 1990 final
rule (55 FR 36024).) A commenter stated that although DRG 20 would
provide a higher payment for these cases, it would still be inadequate
to cover the costs of treating these patients, and we agreed that we
would monitor this issue.
We have recently received requests that we again review this
assignment. These commenters stated that the treatment for these cases
remains very costly and often entails long hospital stays. Therefore,
we conducted an analysis of the cases assigned to DRG 20 using the 10
percent random sample of the FY 1995 MedPAR file that we use for
analyzing possible classification changes.
Cases coded with 357.0 comprise approximately 20 percent of the
cases assigned to DRG 20. As the commenters predicted, the average
standardized charges for these cases, approximately $22,400, was higher
than the average charge for the DRG, approximately $17,100. However,
the length of stay was only slightly higher, 9.1 days compared to 8.4.
We believe that DRG 20 is the appropriate assignment clinically for
Guillain-Barre cases and the average charge is well within the
variation in charges for this DRG. In addition, DRG 20 is the most
resource-intensive, and, thus, the highest-weighted medical DRG in MDC
1.
However, in reviewing the other cases assigned to DRG 20, we noted
that the average charges for two diagnoses were significantly lower
than the overall average charge. These diagnoses, herpes zoster of the
nervous system (code 053.10) and herpes zoster of the nervous system,
NEC (code 053.19) had average charges of only $7,700 and $7,100,
respectively. They also had significantly lower average lengths of stay
(4.4 and 4.2 days, respectively). Because these two diagnoses also
account for approximately 20 percent of the cases in DRG 20, their low
average charge has the effect of significantly lowering the average
charge for the DRG. Removing these two codes from DRG 20 increases the
average charge to approximately $20,000. After reviewing the remaining
medical DRGs in MDC 1, we believe that reassigning codes 053.10 and
053.19 to DRGs 18 and 19 is appropriate both clinically and in terms of
resource consumption. In the 10 percent MedPAR file, these DRGs had an
average charge of approximately $8,000 and $5,300, respectively.
Therefore, we are proposing to make this DRG classification change
effective for FY 1997. This change would significantly increase the
relative weight for DRG 20 and provide higher payment for the Guillain-
Barre cases. The proposed weight for DRG 20 is 2.4782, an increase of
17 percent over the FY 1996 weight of 2.1157.
4. MDC 5 (Diseases and Disorders of the Circulatory System)
Effective for discharges occurring on or after October 1, 1995, we
created a new code for insertion of a coronary artery stent (procedure
code 36.06). Until creation of the new code, insertion of coronary
artery stent had been included in the codes for percutaneous
transluminal coronary angioplasty (PTCA) (procedure codes 36.01, 36.02,
and 36.05).
As discussed above in section II.B.2, when a new code is
introduced, our longstanding practice is to assign it to the same DRG
category as its predecessor code or codes. Therefore, in the June 2,
1995 proposed rule, we assigned procedure code 36.06 to DRG 112
(Percutaneous Cardiovascular Procedures), the DRG to which PTCA is
assigned. In response to comments received, in the September 1, 1995
final rule, we explained our policy on DRG assignment of new codes (60
FR 45785). We also stated that the resource use and other data
associated with procedure code 36.06 will be available in the FY 1996
Medicare cases which are used for analysis as part of FY 1998 DRG
changes. We will evaluate the DRG assignment of coronary artery stent
insertion at that time.
Since publication of the September 1, 1995 final rule, we have
received data on stent cases provided by the manufacturer of one of the
two stent devices currently approved by the Food and Drug
Administration (FDA). In addition, the manufacturer has provided us
with an analysis of the charges and length of stay of approximately
7,500 Medicare patients who received stents in FY 1995. Because there
was no code for the procedure during that year, the manufacturer
matched its list of stent recipients with the FY 1995 MedPAR file.
The manufacturer's analysis found that the FY 1995 average charge
for PTCA cases without stent is approximately $15,700 and the average
charge for cases with stent is approximately $21,000. However, our
analysis of the data shows that there is wide variation in the hospital
standardized charges reported for cases with implant of coronary artery
stent. Individual hospital average charges for these cases range from
about $9,000 to over $45,000.
This inconsistency in the data illustrates why our policy of not
reassigning new codes until we have collected an entire year of coded
Medicare data for analysis is prudent. The uncertainty associated with
using incomplete data collected outside the
[[Page 27448]]
Medicare program that cannot be verified remains a problem. Therefore,
we are not proposing any DRG assignment change for implant of coronary
artery stent. As noted above, a full year of coded FY 1996 Medicare
data will be available in early 1997 for analysis. We will review the
data at that time, and any proposed DRG changes will be announced in
the FY 1998 proposed rule.
5. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
In the September 1, 1995 final rule (60 FR 45790), we responded to
a comment we received regarding the DRG assignment in MDC 8 of bipolar
hip replacement cases. The commenter requested that cases of bipolar
hip replacement be assigned to DRGs 210, 211, and 212 (Hip and Femur
Procedures Except Major Joint) rather than to its current assignment,
DRG 209 (Major Joint and Limb Reattachment Procedures of Lower
Extremity). The commenter stated that the procedure for partial hip
replacement (code 81.52) is very similar to the procedure for open
reduction of fracture of the femur with internal fixation (code 79.35),
which is assigned to DRGs 210, 211, and 212. Further, the commenter
believes that partial hip replacement patients are more frail
individuals than the population that elects total hip replacement
surgery and need longer hospital stays to recover.
In the September 1, 1995 final rule, we stated that we would
reexamine this assignment as part of our DRG agenda for FY 1997. Using
the FY 1995 MedPAR file, we compared charges and lengths of stay for
cases assigned to DRG 209 in which the procedures 81.51 (total hip
replacement), 81.52, and 81.53 (revision of hip replacement) were
performed with the charges for the entire DRG. The average standardized
charges for these cases are very similar to each other as well as the
other cases assigned to DRG 209. The average charge was $18,310 for
partial hip replacement, $19,924 for total hip replacement, and $23,094
for revision of hip replacement. The $1,278 difference between the
average charge for partial hip replacement cases in DRG 209 and the
average charge of $19,588 for all cases in DRG 209 is within the normal
range of charges for that DRG. However, the average charge for cases in
DRG 210 was $15,119, or $2,157 less than the partial hip replacement
charges.
A comparison of lengths of stay yields slightly different results.
The partial hip replacement cases in DRG 209 had an average stay of 8.6
days. The overall average lengths of stay for DRGs 209 and 210 were 6.7
days and 8.5 days, respectively. Based on these data alone, it would
seem that the commenter is correct that partial hip replacement
patients are more similar to the patients in DRG 210, in terms of
hospital length of stay. However, we also must consider these cases'
higher average charges. The higher charges of the partial hip
replacement cases indicate that they are more resource-intense than the
cases in DRG 210. The proposed relative weights for DRG 209 and 210 are
2.2617 and 1.8458, respectively. Therefore, we believe that DRG 209 is
the most appropriate assignment for procedure code 81.52 so that
payment will most closely relate to the costs of care for these
patients.
6. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in assignment of the case
to a different DRG within the MDC to which the principal diagnosis is
assigned. It is, therefore, necessary to have a decision rule by which
these cases are assigned to a single DRG. The surgical hierarchy, an
ordering of surgical classes from most to least resource intensive,
performs that function. Its application ensures that cases involving
multiple surgical procedures are assigned to the DRG associated with
the most resource-intensive surgical class.
Because the relative resource intensity of surgical classes can
shift as a function of DRG reclassification and recalibration, we
reviewed the surgical hierarchy of each MDC, as we have for previous
reclassifications, to determine if the ordering of classes coincided
with the intensity of resource utilization, as measured by the same
billing data used to compute the DRG relative weights.
A surgical class can be composed of one or more DRGs. For example,
in MDC 5, the surgical class ``heart transplant'' consists of a single
DRG (DRG 103) and the class ``coronary bypass'' consists of two DRGs
(DRGs 106 and 107). Consequently, in many cases, the surgical hierarchy
has an impact on more than one DRG. The methodology for determining the
most resource-intensive surgical class, therefore, involves weighting
each DRG for frequency to determine the average resources for each
surgical class. For example, assume surgical class A includes DRGs 1
and 2 and surgical class B includes DRGs 3, 4, and 5, and that the
average charge of DRG 1 is higher than that of DRG 3, but the average
charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To
determine whether surgical class A should be higher or lower than
surgical class B in the surgical hierarchy, we would weight the average
charge of each DRG by frequency (that is, by the number of cases in the
DRG) to determine average resource consumption for the surgical class.
The surgical classes would then be ordered from the class with the
highest average resource utilization to that with the lowest, with the
exception of ``other OR procedures'' as discussed below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class, which may sometimes occur in
cases involving multiple procedures, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average relative
weight is ordered above a surgical class with a higher average relative
weight. For example, the ``other OR procedures'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weight for the DRG
or DRGs in that surgical class may be higher than that for other
surgical classes in the MDC. The ``other OR procedures'' class is a
group of procedures that are least likely to be related to the
diagnoses in the MDC but are occasionally performed on patients with
these diagnoses. Therefore, these procedures should only be considered
if no other procedure more closely related to the diagnoses in the MDC
has been performed.
A second example occurs when the difference between the average
weights for two surgical classes is very small. We have found that
small differences generally do not warrant reordering of the hierarchy
since, by virtue of the hierarchy change, the relative weights are
likely to shift such that the higher-ordered surgical class has a lower
average weight than the class ordered below it.
Based on the preliminary recalibration of the DRGs, we are
proposing to modify the surgical hierarchy as set forth below. As we
stated in the September 1, 1989 final rule (54 FR 36457), we are unable
to test the effects of the proposed revisions to the surgical hierarchy
and to reflect these changes in the proposed relative
[[Page 27449]]
weights due to the unavailability of revised GROUPER software at the
time this proposed rule is prepared. Rather, we simulate most major
classification changes to approximate the placement of cases under the
proposed reclassification and then determine the average charge for
each DRG. These average charges then serve as our best estimate of
relative resource use for each surgical class. We test the proposed
surgical hierarchy changes after the revised GROUPER is received and
reflect the final changes in the DRG relative weights in the final
rule. Further, as discussed below in section II.C of this preamble, we
anticipate that the final recalibrated weights will be somewhat
different from those proposed, since they will be based on more
complete data. Consequently, further revision of the hierarchy, using
the above principles, may be necessary in the final rule.
At this time, we would revise the surgical hierarchy for the Pre-
MDC DRGs, MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth and
Throat), and MDC 10 (Endocrine, Nutritional and Metabolic Diseases and
Disorders) as follows:
In the Pre-MDC DRGs, we would reorder Tracheostomy Except
for Face, Mouth and Neck Diagnoses (DRG 483) above Liver Transplant
(DRG 480).
In MDC 3, we would reorder Cleft Lip and Palate Repair
(DRG 52) and Sinus and Mastoid Procedures (DRGs 53 and 54) above
Tonsillectomy and Adenoidectomy, Except Tonsillectomy and/or
Adenoidectomy Only (DRGs 57 and 58).
In MDC 10, we would reorder Adrenal and Pituitary
Procedures (DRG 286) above Amputation of Lower Limb for Endocrine,
Nutritional, and Metabolic Disorders (DRG 285).
7. Refinement of Complications and Comorbidities List
There is a standard list of diagnoses that are considered
complications or comorbidities (CCs). We developed this list using
physician panels to include those diagnoses that, when present as a
secondary condition, would be considered a substantial complication or
comorbidity.
In previous years, we have made changes to the standard list of
CCs, either by adding new CCs or deleting CCs already on the list. At
this time, we do not propose to delete any of the diagnosis codes on
the CC list.
In the September 1, 1995 final rule (60 FR 45782), we added
diagnosis code 008.49 (Bacterial enteritis) to the CC list. In response
to a request from one commenter that we also add diagnosis code 008.45
(Clostridium difficile), we stated that we would review that request as
part of our DRG analysis for FY 1997. We have reevaluated diagnosis
code 008.45 as well as the remainder of the ``family'' of codes
assigned to Intestinal infections due to other specified bacteria
(008.41, 008.42, 008.43, 008.44, 008.46, and 008.47). Our analysis
shows that all of these diagnoses, when present as a secondary
condition, do lead to higher resource use. Therefore, we are proposing
to add the following diagnosis codes to the CC list:
008.41 Intestinal infections due to staphylococcus
008.42 Intestinal infections due to pseudomonas
008.43 Intestinal infections due to campylobacter
008.44 Intestinal infections due to yersinia enterocolitica
008.45 Intestinal infections due to clostridium difficile
008.46 Intestinal infections due to other anaerobes
008.47 Intestinal infections due to other gram-negative bacteria
These diagnoses would be considered CCs for any principal diagnosis
not shown in Table 6f, Additions to the CC Exclusions List (see
discussion of CC Exclusions list in section V of the Addendum below).
This same commenter also requested that we add the following codes
to the CC list:
331.0 Alzheimer's disease
423.9 Unspecified disease of the pericardium
348.5 Cerebral edema
333.4 Huntington's chorea
458.0 Orthostatic hypotension
458.9 Hypotension, not otherwise specified
Our analysis of these codes demonstrates that their presence as a
secondary diagnosis does not significantly add to the resource use of
the case. Therefore, we are not proposing to add them to the CC list.
Finally, the commenter suggested that the following diagnoses be
added as cardiovascular complications for DRG 121 (Circulatory
Disorders with AMI and Cardiovascular Complications, Discharged Alive):
434.xx Occlusion of cerebral arteries
436 Acute, but ill-defined, cerebrovascular disease
Using the 10 percent analysis file of the FY 1995 MedPAR data, we
analyzed the cases assigned to DRG 121 that had these diagnoses coded
as secondary conditions. The charges associated with those cases were
indeed comparable to the other cases assigned to DRG 121. When we
sought the advice of our medical specialists (physicians who work
directly for or under contract with HCFA), however, they strongly
opposed adding these codes to the list of conditions for DRG 121 based
on the fact that these are not cardiovascular complications. Therefore,
they are not clinically similar to other cases assigned to this DRG.
However, our analysis of this DRG did reveal a large variation in
the charges and lengths of stay within this DRG. We believe that a
close examination of the list of complicating conditions assigned to
DRG 121 is needed. Therefore, we plan to perform a thorough analysis of
the cases assigned to that DRG as part of our DRG analysis agenda for
FY 1998. In the meantime, we are not proposing any change to DRG 121.
In the September 1, 1987 final notice concerning changes to the DRG
classification system (52 FR 33143), we modified the GROUPER logic so
that certain diagnoses included on the standard list of CCs would not
be considered a valid CC in combination with a particular principal
diagnosis. Thus, we created the CC Exclusions List. We made these
changes to preclude coding of CCs for closely related conditions, to
preclude duplicative coding or inconsistent coding from being treated
as CCs, and to ensure that cases are appropriately classified between
the complicated and uncomplicated DRGs in a pair.
In the May 19, 1987 proposed notice concerning changes to the DRG
classification system (52 FR 18877), we explained that the excluded
secondary diagnoses were established using the following five
principles:
Chronic and acute manifestations of the same condition
should not be considered CCs for one another (as subsequently corrected
in the September 1, 1987 final notice (52 FR 33154)).
Specific and nonspecific (that is, not otherwise specified
(NOS)) diagnosis codes for a condition should not be considered CCs for
one another.
Conditions that may not co-exist, such as partial/total,
unilateral/bilateral, obstructed/unobstructed, and benign/malignant,
should not be considered CCs for one another.
The same condition in anatomically proximal sites should
not be considered CCs for one another.
Closely related conditions should not be considered CCs
for one another.
The creation of the CC Exclusions List was a major project
involving hundreds of codes. The FY 1988 revisions were intended to be
only a first step toward refinement of the CC list in that the
[[Page 27450]]
criteria used for eliminating certain diagnoses from consideration as
CCs were intended to identify only the most obvious diagnoses that
should not be considered complications or comorbidities of another
diagnosis. For that reason, and in light of comments and questions on
the CC list, we have continued to review the remaining CCs to identify
additional exclusions and to remove diagnoses from the master list that
have been shown not to meet the definition of a CC. (See the September
30, 1988 final rule for the revision made for the discharges occurring
in FY 1989 (53 FR 38485); the September 1, 1989 final rule for the FY
1990 revision (54 FR 36552); the September 4, 1990 final rule for the
FY 1991 revision (55 FR 36126); the August 30, 1991 final rule for the
FY 1992 revision (56 FR 43209); the September 1, 1992 final rule for
the FY 1993 revision (57 FR 39753); the September 1, 1993 final rule
for the FY 1994 revisions (58 FR 46278); the September 1, 1994 final
rule for the FY 1995 revisions (59 FR 45334); and the September 1, 1995
rule for the FY 1996 revisions (60 FR 45782).)
We are proposing a limited revision of the CC Exclusions List to
take into account the changes that will be made in the ICD-9-CM
diagnosis coding system effective October 1, 1996, as well as the
proposed CC changes described above. (See section II.B.8, below, for a
discussion of ICD-9-CM changes.) These proposed changes are being made
in accordance with the principles established when we created the CC
Exclusions List in 1987.
The changes discussed above have been added to Table 6g, Additions
to the CC Exclusions List, in section V of the Addendum to this
proposed rule.
Tables 6g and 6h in section V of the Addendum to this proposed rule
contain the proposed revisions to the CC Exclusions List that would be
effective for discharges occurring on or after October 1, 1996. Each
table shows the principal diagnoses with proposed changes to the
excluded CCs. Each of these principal diagnoses is shown with an
asterisk and the additions or deletions to the CC Exclusions List are
provided in an indented column immediately following the affected
principal diagnosis.
CCs that are added to the list are in Table 6g--Additions to the CC
Exclusions List. Beginning with discharges on or after October 1, 1996,
the indented diagnoses will not be recognized by the GROUPER as valid
CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6h--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 1996, the indented diagnoses will be recognized by the GROUPER as
valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can
be obtained from the National Technical Information Service (NTIS) of
the Department of Commerce. It is available in hard copy for $92.00
plus $6.00 shipping and handling and on microfiche for $20.50, plus
$4.00 for shipping and handling. A request for the FY 1988 CC
Exclusions List (which should include the identification accession
number, (PB) 88-133970) should be made to the following address:
National Technical Information Service; United States Department of
Commerce; 5285 Port Royal Road; Springfield, Virginia 22161; or by
calling (703) 487-4650.
Users should be aware of the fact that all revisions to the CC
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, and
1996) and those in Tables 6g and 6h of this document must be
incorporated into the list purchased from NTIS in order to obtain the
CC Exclusions List applicable for discharges occurring on or after
October 1, 1996.
Alternatively, the complete documentation of the GROUPER logic,
including the current CC Exclusions List, is available from 3M/Health
Information Systems (HIS), which, under contract with HCFA, is
responsible for updating and maintaining the GROUPER program. The
current DRG Definitions Manual, Version 13.0, is available for $195.00,
which includes $15.00 for shipping and handling. Version 14.0 of this
manual, which will include the final FY 1997 DRG changes, will be
available in October 1996 for $195.00. These manuals may be obtained by
writing 3M/HIS at the following address: 100 Barnes Road; Wallingford,
Connecticut 06492; or by calling (203) 949-0303. Please specify the
revision or revisions requested.
8. Review of Procedure Codes in DRGs 468, 476, and 477 Each Year, We
Review Cases Assigned to DRG 468
(Extensive OR Procedure Unrelated to Principal Diagnosis), DRG 476
(Prostatic OR Procedure Unrelated to Principal Diagnosis), and DRG 477
(Nonextensive OR Procedure Unrelated to Principal Diagnosis) in order
to determine whether it would be appropriate to change the procedures
assigned among these DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none
of the OR procedures performed is related to the principal diagnosis.
These DRGs are intended to capture atypical cases, that is, those cases
not occurring with sufficient frequency to represent a distinct,
recognizable clinical group. DRG 476 is assigned to those discharges in
which one or more of the following prostatic procedures are performed
and are unrelated to the principal diagnosis:
60.0 Incision of prostate
60.12 Open biopsy of prostate
60.15 Biopsy of periprostatic tissue
60.18 Other diagnostic procedures on prostate and periprostatic tissue
60.21 Transurethral prostatectomy
60.29 Other transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostatic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with
DRG 477 assigned to those discharges in which the only procedures
performed are nonextensive procedures that are unrelated to the
principal diagnosis. The original list of the ICD-9-CM procedure codes
for the procedures we consider nonextensive procedures if performed
with an unrelated principal diagnosis was published in Table 6C in
section IV of the Addendum to the September 30, 1988 final rule (53 FR
38591). As part of the final rules published on September 4, 1990,
August 30, 1991, September 1, 1992, September 1, 1993, September 1,
1994, and September 1, 1995, we moved several other procedures from DRG
468 to 477. (See 55 FR 36135, 56 FR 43212, 57 FR 23625, 58 FR 46279, 59
FR 45336, and 60 FR 45783, respectively.)
a. Adding Procedure Codes to MDCs
We annually conduct a review of procedures producing DRG 468 or 477
assignments on the basis of volume of cases in these DRGs with each
procedure. Our medical consultants then identify those procedures
occurring in conjunction with certain principal diagnoses with
sufficient frequency to justify adding them to one of the surgical DRGs
for the MDC in which the diagnosis falls. This year's review did not
identify any necessary changes; therefore, we are not proposing
[[Page 27451]]
to move any procedures from DRG 468 or DRG 477 to one of the surgical
DRGs.
b. Reassignment of Procedures Among DRGs 468, 476, and 477
We also reviewed the list of procedures that produce assignments to
DRGs 468, 476, and 477 to ascertain if any of those procedures should
be moved from one of these DRGs to another based on average charges and
length of stay. Generally, we move only those procedures for which we
have an adequate number of discharges to analyze the data. Based on our
review this year, we are proposing to move one procedure from DRG 468
to DRG 477.
In reviewing the list of OR procedures that produce DRG 468
assignments, we analyzed the average charge and length of stay data for
cases assigned to that DRG to identify those procedures that are more
similar to the discharges that currently group to either DRG 476 or
477. We identified one procedure--Closed endoscopic biopsy of lung
(code 33.27), a needle biopsy--that is significantly less resource
intensive than the other procedures assigned to DRG 468. Therefore, we
are proposing to move procedure code 33.27 to the list of procedures
that result in assignment to DRG 477.
In reviewing the list of procedures assigned to DRG 477, we did not
identify any procedures that should be assigned to either DRG 468 or
476. We did, however, identify the following procedures that we believe
should be reassigned from an OR to a non-OR designation:
08.81 Linear repair of laceration of eyelid or eyebrow
08.82 Repair of laceration involving lid margin, partial-thickness
08.83 Other repair of laceration of eyelid, partial thickness
08.84 Repair of laceration involving lid margin, full-thickness
08.85 Other repair of laceration of eyelid, full-thickness
08.86 Lower eyelid rhytidectomy
08.87 Upper eyelid rhytidectomy
08.89 Other eyelid repair
Our analysis of the data associated with these eyelid repair
procedures leads us to conclude that the procedures are performed
following accidental injury or falls, incurred while the patient is in
the hospital. These procedures, which are normally performed at bedside
and do not necessitate a trip to the operating room, are significantly
less resource intensive than other procedures designated as OR
procedures. Therefore, we are proposing to change the procedures from
OR to non-OR procedures. We note that these procedures are assigned to
surgical DRGs in MDCs 2, 9, 21, 22, and 24. With this proposed change,
cases in which procedure codes 08.81 through 08.89 are the only OR
procedure codes listed would no longer be assigned to a surgical DRG.
All of these proposed changes would be effective with discharges
occurring on or after October 1, 1996.
9. Changes to the ICD-9-CM Coding System
As discussed above in section II.B.1 of this preamble, the ICD-9-CM
is a coding system that is used for the reporting of diagnoses and
procedures performed on a patient. In September 1985, the ICD-9-CM
Coordination and Maintenance Committee was formed. This is a Federal
interdepartmental committee charged with the mission of maintaining and
updating the ICD-9-CM. That mission includes approving coding changes,
and developing errata, addenda, and other modifications to the ICD-9-CM
to reflect newly developed procedures and technologies and newly
identified diseases. The Committee is also responsible for promoting
the use of Federal and non-Federal educational programs and other
communication techniques with a view toward standardizing coding
applications and upgrading the quality of the classification system.
The Committee is co-chaired by the National Center for Health
Statistics (NCHS) and HCFA. The NCHS has lead responsibility for the
ICD-9-CM diagnosis codes included in Volume 1--Diseases: Tabular List
and Volume 2--Diseases: Alphabetic Index, while HCFA has lead
responsibility for the ICD-9-CM procedure codes included in Volume 3--
Procedures: Tabular List and Alphabetic Index.
The Committee encourages participation in the above process by
health-related organizations. In this regard, the Committee holds
public meetings for discussion of educational issues and proposed
coding changes. These meetings provide an opportunity for
representatives of recognized organizations in the coding fields, such
as the American Health Information Management Association (AHIMA)
(formerly American Medical Record Association (AMRA)), the American
Hospital Association (AHA), and various physician specialty groups as
well as physicians, medical record administrators, health information
management professionals, and other members of the public to contribute
ideas on coding matters. After considering the opinions expressed at
the public meetings and in writing, the Committee formulates
recommendations, which then must be approved by the agencies.
The Committee presented proposals for coding changes at public
meetings held on May 5 and November 30, 1995, and finalized the coding
changes after consideration of comments received at the meetings and in
writing within 30 days following the November 1995 meeting. The initial
meeting for consideration of coding issues for implementation in FY
1998 will be held on June 6, 1996. Copies of the minutes of these
meetings may be obtained by writing to one of the co-chairpersons
representing NCHS and HCFA. We encourage commenters to address
suggestions on coding issues involving diagnosis codes to: Donna
Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance
Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, Maryland
20782. Comments may be sent by E-mail to: alb8@nch09a.em.cdc.gov.
Questions and comments concerning the procedure codes should be
addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination
and Maintenance Committee; HCFA, Office of Hospital Policy; Division of
Prospective Payment System; C5-06-27; 7500 Security Boulevard;
Baltimore, Maryland 21244-1850. Comments may be sent by E-mail to:
pbrooks@hcfa.gov.
The ICD-9-CM code changes that have been approved will become
effective October 1, 1996. The new ICD-9-CM codes are listed, along
with their proposed DRG classifications, in Tables 6a and 6b (New
Diagnosis Codes and New Procedure Codes, respectively) in section V of
the Addendum to this proposed rule. As we stated above, the code
numbers and their titles were presented for public comment in the ICD-
9-CM Coordination and Maintenance Committee meetings. Both oral and
written comments were considered before the codes were approved.
Therefore, we are soliciting comments only on the proposed DRG
classification.
Further, the Committee has approved the expansion of certain ICD-9-
CM codes to require an additional digit for valid code assignment.
Diagnosis codes that have been replaced by expanded codes, other codes,
or have been deleted are in Table 6c (Invalid Diagnosis Codes). The
procedure codes that have been replaced by expanded codes or have been
deleted are in Table 6d (Invalid Procedure Codes). These invalid
diagnosis and procedure codes will not be recognized by the GROUPER
beginning with discharges occurring on or after October 1, 1996. The
[[Page 27452]]
corresponding new or expanded codes are included in Tables 6a and 6b.
Revisions to diagnosis and procedure code titles are in Tables 6e
(Revised Diagnosis Code Titles) and 6f (Revised Procedure Code Titles),
which also include the proposed DRG assignments for these revised
codes.
C. Recalibration of DRG Weights
We are proposing to use the same basic methodology for the FY 1997
recalibration as we did for FY 1996. (See the September 1, 1995 final
rule (60 FR 45791).) That is, we would recalibrate the weights based on
charge data for Medicare discharges. However, we would use the most
current charge information available, the FY 1995 MedPAR file, rather
than the FY 1994 MedPAR file. The MedPAR file is based on fully-coded
diagnostic and surgical procedure data for all Medicare inpatient
hospital bills.
The proposed recalibrated DRG relative weights are constructed from
FY 1995 MedPAR data, based on bills received by HCFA through December
1995, from all hospitals subject to the prospective payment system and
short-term acute care hospitals in waiver States. The FY 1995 MedPAR
file includes data for approximately 10.6 million Medicare discharges.
The methodology used to calculate the proposed DRG relative weights
from the FY 1995 MedPAR file is as follows:
To the extent possible, all the claims were regrouped
using the proposed DRG classification revisions discussed above in
section II.B of this preamble. As noted in section II.B.6, due to the
unavailability of revised GROUPER software, we simulate most major
classification changes to approximate the placement of cases under the
proposed reclassification. However, there are some changes that cannot
be modeled.
Charges were standardized to remove the effects of
differences in area wage levels, indirect medical education costs,
disproportionate share payments, and, for hospitals in Alaska and
Hawaii, the applicable cost-of-living adjustment.
The average standardized charge per DRG was calculated by
summing the standardized charges for all cases in the DRG and dividing
that amount by the number of cases classified in the DRG.
We then eliminated statistical outliers, using the same
criteria as was used in computing the current weights. That is, all
cases that are outside of 3.0 standard deviations from the mean of the
log distribution of both the charges per case and the charges per day
for each DRG.
The average charge for each DRG was then recomputed
(excluding the statistical outliers) and divided by the national
average standardized charge per case to determine the relative weight.
A transfer case is counted as a fraction of a case based on the ratio
of its length of stay to the geometric mean length of stay of the cases
assigned to the DRG. That is, a 5-day length of stay transfer case
assigned to a DRG with a geometric mean length of stay of 10 days is
counted as 0.5 of a total case.
We established the relative weight for heart and heart-
lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner
consistent with the methodology for all other DRGs except that the
transplant cases that were used to establish the weights were limited
to those Medicare-approved heart, heart-lung, liver, and lung
transplant centers that have cases in the FY 1995 MedPAR file.
(Medicare coverage for heart, heart-lung, liver, and lung transplants
is limited to those facilities that have received approval from HCFA as
transplant centers.)
Acquisition costs for kidney, heart, heart-lung, liver,
and lung transplants continue to be paid on a reasonable cost basis.
Unlike other excluded costs, the acquisition costs are concentrated in
specific DRGs (DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant
for heart and heart-lung transplants); DRG 480 (Liver Transplant); and
DRG 495 (Lung Transplant)). Because these costs are paid separately
from the prospective payment rate, it is necessary to make an
adjustment to prevent the relative weights for these DRGs from
including the effect of the acquisition costs. Therefore, we subtracted
the acquisition charges from the total charges on each transplant bill
that showed acquisition charges before computing the average charge for
the DRG and before eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a
threshold of 10 cases as the minimum number of cases required to
compute a reasonable weight. We propose to use that same case threshold
in recalibrating the DRG weights for FY 1997. Using the FY 1995 MedPAR
data set, there are 37 DRGs that contain fewer than 10 cases. We
computed the weights for the 37 low-volume DRGs by adjusting the FY
1996 weights of these DRGs by the percentage change in the average
weight of the cases in the other DRGs. We note that the FY 1996 weights
for the low-volume DRGs were recalculated based on non-Medicare data we
acquired from 19 States. This was the first update of the weights since
they were initially calculated for FY 1984 based on data from Maryland
and Michigan. For a complete description of this process, see the
September 1, 1995 final rule (60 FR 45781).
The weights developed according to the methodology described above,
using the proposed DRG classification changes, result in an average
case weight that is different from the average case weight before
recalibration. Therefore, the new weights are normalized by an
adjustment factor, so that the average case weight after recalibration
is equal to the average case weight before recalibration. This
adjustment is intended to ensure that recalibration by itself neither
increases nor decreases total payments under the prospective payment
system.
Section 1886(d)(4)(C)(iii) of the Act requires that beginning with
FY 1991, reclassification and recalibration changes be made in a manner
that assures that the aggregate payments are neither greater than nor
less than the aggregate payments that would have been made without the
changes. Although normalization is intended to achieve this effect,
equating the average case weight after recalibration to the average
case weight before recalibration does not necessarily achieve budget
neutrality with respect to aggregate payments to hospitals because
payment to hospitals is affected by factors other than average case
weight. Therefore, as we have done in past years and as discussed in
section II.A.4.b of the Addendum to this proposed rule, we are
proposing to make a budget neutrality adjustment to assure that the
requirement of section 1886(d)(4)(C)(iii) of the Act is met.
III. Proposed Changes to the Hospital Wage Index
A. Background
Section 1886(d)(3)(E) of the Act requires that, as part of the
methodology for determining prospective payments to hospitals, the
Secretary must adjust the standardized amounts ``for area differences
in hospital wage levels by a factor (established by the Secretary)
reflecting the relative hospital wage level in the geographic area of
the hospital compared to the national average hospital wage level.'' In
accordance with the broad discretion conferred by this provision, we
currently define hospital labor market areas based on the definitions
of Metropolitan Statistical Areas (MSAs) (and New England County
Metropolitan Areas), issued by the Office of Management and Budget. In
addition, as discussed below, we adjust the wage
[[Page 27453]]
index to take into account the geographic reclassification of hospitals
in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act.
Section 1886(d)(3)(E) of the Act also requires that the wage index
be updated annually beginning October 1, 1993. Furthermore, this
section provides that the Secretary base the update on a survey of
wages and wage-related costs of short-term, acute care hospitals. The
survey should measure, to the extent feasible, the earnings and paid
hours of employment by occupational category, and must exclude the
wages and wage-related costs incurred in furnishing skilled nursing
services.
B. FY 1997 Wage Index Update
The proposed FY 1997 wage index (effective for hospital discharges
occurring on or after October 1, 1996 and before October 1, 1997) is
based on the data collected from the Medicare cost reports submitted by
hospitals for cost reporting periods beginning in FY 1993 (the FY 1996
wage index is based on FY 1992 wage data). We propose to use the same
categories of data that were used in the FY 1996 wage index. Therefore,
the proposed FY 1997 wage index reflects the following:
Total salaries and hours from short-term, acute care
hospitals.
Home office costs and hours.
Fringe benefits associated with hospital and home office
salaries.
Direct patient care contract labor costs and hours.
The exclusion of salaries and hours for nonhospital type
services such as skilled nursing facility services, home health
services, or other subprovider components that are not subject to the
prospective payment system.
Finally, we are also proposing to make a minor revision to
Sec. 412.63(s)(1) to state clearly that we update the wage index
annually as required by section 1886(d)(3)(E) of the Act.
1. Verification of Wage Data From the Medicare Cost Report
The data for the proposed FY 1997 wage index were obtained from
Worksheet S-3, Part II of the Medicare cost report. The data file used
to construct the proposed wage index includes FY 1993 data submitted to
the Hospital Cost Report Information System (HCRIS) file as of the end
of January 1996. As in past years, we performed an intensive review of
the wage data, mostly through the use of edits designed to identify
aberrant data.
Of the 5,222 hospitals in the data base, 2,814 hospitals had data
elements that failed an initial edit. In mid-February 1996,
intermediaries contacted hospitals to revise or verify data elements
that resulted in the edit failures. Next, to check any revisions since
the first edit, as well as to apply additional edits based on the
distribution of the data, we subjected all of the data to edits a
second time. The intermediaries were instructed to transmit any
revisions in hospitals' wage data made as a result of this second
review. As of March 14, 1996, only 21 hospitals still had unresolved
data elements. These unresolved data elements are included in the
calculation of the proposed FY 1997 wage index pending their resolution
before calculation of the final FY 1997 wage index. We have instructed
the intermediaries to complete their verification of questionable data
elements and to transmit any changes to the wage data (through HCRIS)
no later than June 17, 1996. We expect that all unresolved data
elements will be resolved by that date, and that the revised data will
be reflected in the final rule.
2. Computation of the Wage Index
The method used to compute the proposed wage index is as follows:
Step 1--As noted above, we are proposing to base the FY 1997 wage
index on wage data reported on the FY 1993 cost reports. We gathered
data from each of the non-Federal short-term, acute care hospitals for
which data were reported on the Worksheet S-3, Part II of the Medicare
cost report for the hospital's cost reporting periods beginning on or
after October 1, 1992 and before October 1, 1993. In addition, we
included data from a few hospitals that had cost reporting periods
beginning in September 1992 and reported a cost reporting period
exceeding 52 weeks. The data were included because no other data from
these hospitals would be available for the cost reporting period
described above, and particular labor market areas might be affected
due to the omission of these hospitals. However, we generally describe
these wage data as FY 1993 data.
Step 2--For each hospital, we subtracted the excluded salaries
(that is, direct salaries attributable to skilled nursing facility
services, home health services, and other subprovider components not
subject to the prospective payment system) from gross hospital salaries
to determine net hospital salaries. To determine total salaries plus
fringe benefits, we added direct patient care contract labor costs,
hospital fringe benefits, and any home office salaries and fringe
benefits reported by the hospital, to the net hospital salaries.
Step 3--For each hospital, we adjusted the total salaries plus
fringe benefits resulting from Step 2 to a common period to determine
total adjusted salaries. To make the wage inflation adjustment, we used
the percentage change in average hourly earnings for each 30-day
increment from October 14, 1992 through September 15, 1994, for
hospital industry workers from Standard Industry Classification 806,
Bureau of Labor Statistics Employment and Earnings Bulletin. The annual
inflation rates used were 4.8 percent for FY 1992, 3.6 percent for FY
1993, and 2.7 percent for FY 1994. The inflation factors used to
inflate the hospital's data were based on the midpoint of the cost
reporting period as indicated below.
Midpoint of Cost Reporting Period
------------------------------------------------------------------------
After Before Adjustment factor
------------------------------------------------------------------------
10/14/92............... 11/15/92 1.044482
11/14/92............... 12/15/92 1.041408
12/14/92............... 01/15/93 1.038343
01/14/93............... 02/15/93 1.035287
02/14/93............... 03/15/93 1.032240
03/14/93............... 04/15/93 1.029203
04/14/93............... 05/15/93 1.026174
05/14/93............... 06/15/93 1.023154
06/14/93............... 07/15/93 1.020143
07/14/93............... 08/15/93 1.017141
08/14/93............... 09/15/93 1.014147
09/14/93............... 10/15/93 1.011163
10/14/93............... 11/15/93 1.008920
11/14/93............... 12/15/93 1.006683
12/14/93............... 01/15/94 1.004450
01/14/94............... 02/15/94 1.002223
02/14/94............... 03/15/94 1.000000
03/14/94............... 04/15/94 0.997782
04/14/94............... 05/15/94 0.995570
05/14/94............... 06/15/94 0.993362
06/14/94............... 07/15/94 0.991159
07/14/94............... 08/15/94 0.988961
08/14/94............... 09/15/94 0.986767
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 1993 and ending December 31, 1993 is June 30, 1993. An
inflation adjustment factor of 1.020143 would be applied to the wages
of a hospital with such a cost reporting period. In addition, for the
data for any cost reporting period that began in FY 1993 and covers a
period of less than 360 days or greater than 370 days, we annualized
the data to reflect a 1-year cost report. Annualization is accomplished
by dividing the data by the number of days in the cost report and then
multiplying the results by 365.
Step 4--For each hospital, we subtracted the reported excluded
hours from the gross hospital hours to determine net hospital hours. We
[[Page 27454]]
increased the net hours by the addition of any direct patient care
contract labor hours and home office hours to determine total hours.
Step 5--As part of our editing process, we deleted data for eight
hospitals for which we lacked sufficient documentation to verify data
that failed edits because the hospitals are no longer participating in
the Medicare program or are in bankruptcy status. We retained the data
for other hospitals that are no longer participating in the Medicare
program because these hospitals reflected the relative wage levels in
their labor market areas during their FY 1993 cost reporting period.
Step 6--Each hospital was assigned to its appropriate urban or
rural labor market area prior to any reclassifications under sections
1886(d)(8)(B) or 1886(d)(10) of the Act. Within each urban or rural
labor market area, we added the total adjusted salaries plus fringe
benefits obtained in Step 3 for all hospitals in that area to determine
the total adjusted salaries plus fringe benefits for the labor market
area.
Step 7--We divided the total adjusted salaries plus fringe benefits
obtained in Step 6 by the sum of the total hours (from Step 4) for all
hospitals in each labor market area to determine an average hourly wage
for the area.
Step 8--We added the total adjusted salaries plus fringe benefits
obtained in Step 3 for all hospitals in the nation and then divided the
sum by the national sum of total hours from Step 4 to arrive at a
national average hourly wage. Using the data as described above, the
national average hourly wage is $19.5094.
Step 9--For each urban or rural labor market area, we calculated
the hospital wage index value by dividing the area average hourly wage
obtained in Step 7 by the national average hourly wage computed in Step
8.
3. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more MSAs are considered to be located in
one of the adjacent MSAs if certain standards are met. Under section
1886(d)(10) of the Act, the Medicare Geographic Classification Review
Board (MGCRB) considers applications by hospitals for geographic
reclassification for purposes of payment under the prospective payment
system.
The methodology for determining the wage index values for
redesignated hospitals is applied jointly to the hospitals located in
those rural counties that were deemed urban under section 1886(d)(8)(B)
of the Act and those hospitals that were reclassified as a result of
the MGCRB decisions under section 1886(d)(10) of the Act. Section
1886(d)(8)(C) of the Act provides that the application of the wage
index to redesignated hospitals is dependent on the hypothetical impact
that the wage data from these hospitals would have on the wage index
value for the area to which they have been redesignated. Therefore, as
provided in section 1886(d)(8)(C) of the Act, the wage index values
were determined by considering the following:
If including the wage data for the redesignated hospitals
reduces the MSA wage index value by 1 percentage point or less, the MSA
wage index value determined exclusive of the wage data for the
redesignated hospitals applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals
reduces the wage index value for the area to which the hospitals are
redesignated by more than 1 percentage point, the hospitals that are
redesignated are subject to the wage index value of the area that
results from including the wage data of the redesignated hospitals (the
``combined'' wage index value). However, the wage index value for the
redesignated hospitals cannot be reduced below the wage index value for
the rural areas of the State in which the hospitals are located.
If including the wage data for the redesignated hospitals
increases the MSA wage index value, the MSA and the redesignated
hospitals receive the combined wage index value.
Rural areas whose wage index values would be reduced by
excluding the data for hospitals that have been redesignated to another
area continue to have their wage index calculated as if no
redesignation had occurred. Those rural areas whose wage index values
increase as a result of excluding the wage data for the hospitals that
have been redesignated to another area have their wage indexes
calculated exclusive of the redesignated hospitals.
The wage index value for an urban area is calculated
exclusive of the wage data for hospitals that have been reclassified to
another area. However, geographic reclassification may not reduce the
wage index for an urban area below the Statewide rural average,
provided the wage index prior to reclassification was greater than the
Statewide rural wage index value.
A change in classification of hospitals from one area to
another may not result in the reduction in the wage index for any urban
area whose wage index is below the rural wage index for the State. This
provision also applies to any urban area that encompasses an entire
State.
We note that, except for those rural areas where redesignation
would reduce the rural wage index value, and those urban areas whose
wage index values are already below the rural wage index and would be
reduced by redesignations, the wage index value for each area is
computed exclusive of the data for hospitals that have been
redesignated from the area for purposes of their wage index. As a
result, several MSAs listed in Table 4a have no hospitals remaining in
the MSA. This is because all the hospitals originally in these MSAs
have been reclassified to another area by the MGCRB. These areas
receive the prereclassified wage index value. The prereclassified wage
index value will apply as long as the MSA remains empty.
The proposed revised wage index values for FY 1997 are shown in
Tables 4a, 4b, and 4c in the Addendum to this proposed rule. Hospitals
that are redesignated should use the wage index values shown in Table
4c. For some areas, more than one wage index value will be shown in
Table 4c. This occurs when hospitals from more than one State are
included in the group of redesignated hospitals, and one State has a
higher Statewide rural wage index value than the wage index value
otherwise applicable to the redesignated hospitals. Tables 4d and 4e
list the average hourly wage for each labor market area, prior to the
redesignation of hospitals, based on the FY 1993 wage data. (We note
that in Tables 4a, 4c, and 4d, we have revised several of the titles
for urban areas to be consistent with OMB titles. For example, the
title for urban area 1123 is changed from Boston-Brockton-Nashua, MA-NH
to Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH. These are
nomenclature changes only.) In addition, Table 3C in the Addendum to
this proposed rule includes the adjusted average hourly wage for each
hospital based on the FY 1993 data. The MGCRB will use the average
hourly wage published in the final rule to evaluate a hospital's
application for reclassification, unless that average hourly wage is
later revised in accordance with the wage data correction policy
described in Sec. 412.63(s)(2). In such cases, the MGCRB will use the
most recent revised data used for purposes of the hospital wage index.
Hospitals that choose to apply before publication of the final rule can
use the proposed wage data in applying to the MGCRB for wage index
reclassifications that would be effective for FY 1998. We note that in
[[Page 27455]]
adjudicating these wage reclassification requests during FY 1997, the
MGCRB will use the average hourly wages for each hospital and labor
market area that are reflected in the final FY 1997 wage index.
At the time this proposed wage index was constructed, the MGCRB had
completed its review. The proposed FY 1997 wage index values
incorporate all 391 hospitals redesignated for purposes of the wage
index (hospitals redesignated under section 1886(d)(8)(B) or
1886(d)(10) of the Act) for FY 1997. The final number of
reclassifications may be different because some MGCRB decisions are
still under review by the Administrator and because some hospitals may
withdraw their requests for reclassification.
Any changes to the wage index that result from withdrawals of
requests for reclassification, wage index corrections, appeals, and the
Administrator's review process will be incorporated into the wage index
values published in the final rule. The changes may affect not only the
wage index value for specific geographic areas, but also whether
redesignated hospitals receive the wage index value for the area to
which they are redesignated, or a wage index that includes the data for
both the hospitals already in the area and the redesignated hospitals.
Further, the wage index value for the area from which the hospitals are
redesignated may be affected.
Under Sec. 412.273, hospitals that have been reclassified by the
MGCRB are permitted to withdraw their applications within 45 days of
the publication of this Federal Register document. The request for
withdrawal of an application for reclassification that would be
effective in FY 1997 must be received by the MGCRB by July 15, 1996. A
hospital that requests to withdraw its application may not later
request that the MGCRB decision be reinstated.
C. Requests for Wage Data Corrections
To allow hospitals more time to evaluate the wage data used to
construct the proposed FY 1997 hospital wage index, we have made
available to the public a diskette containing the FY 1993 hospital wage
data. In a memorandum dated March 1, 1996, we instructed all Medicare
intermediaries to inform the prospective payment hospitals they serve
that the diskette would be available approximately mid-March 1996. The
intermediaries were also instructed to advise hospitals of the
alternative availability of these data either through their
representative hospital organizations or directly from HCFA (using
order forms provided by the intermediary). Additional details on
ordering this data file are discussed below in section VIII.B of this
preamble, ``Requests for Data from the Public.''
In addition, as discussed above in section III.B.3 of this
preamble, Table 3C, in the Addendum to this proposed rule, contains
each hospital's adjusted average hourly wage used to construct the
proposed wage index values. A hospital can verify its average hourly
wage as reflected on its cost report (after taking into account any
adjustments made by the intermediary) by dividing the adjusted average
hourly wage in Table 3C by the applicable wage inflation adjustment
factors as set forth above in Step 3 of the computation of the wage
index. An updated Table 3C (along with applicable wage inflation
adjustment factors) will be included in the final rule.
We believe hospitals have had ample time to ensure the accuracy of
their FY 1993 wage data. Moreover, the ultimate responsibility for
accurately completing the cost report rests with the hospital, which
must attest to the accuracy of the data at the time the cost report is
filed. However, if after review of the diskette or Table 3C, a hospital
believes that its FY 1993 wage data have been incorrectly reported, the
hospital must submit corrections along with complete supporting
documentation to its intermediary by May 15, 1996. To be reflected in
the final wage index, any wage data corrections must be reviewed by the
intermediary and transmitted to HCFA (through HCRIS) on or before June
17, 1996. These deadlines, which correspond to the deadlines we used
last year for the FY 1996 wage index, are necessary to allow sufficient
time to review and process the data so that the final wage index
calculation can be completed for development of the final prospective
payment rates to be published by September 1, 1996. We cannot guarantee
that corrections transmitted to HCFA after June 17, 1996, will be
reflected in the final wage index.
After reviewing requested changes submitted by hospitals,
intermediaries will transmit any revised cost reports to HCRIS and
forward a copy of the revised Worksheet S-3, Part II to the hospitals.
If requested changes are not accepted, fiscal intermediaries will
notify hospitals in writing of reasons why the changes were not
accepted. This procedure will ensure that hospitals have every
opportunity to verify the data that will be used to construct their
wage index values. We believe that fiscal intermediaries are generally
in the best position to make evaluations regarding the appropriateness
of a particular cost and whether it should be included in the wage
index data. However, if a hospital disagrees with the intermediary's
resolution of a requested change, the hospital may contact HCFA in an
effort to resolve the dispute. We note that the June 17 deadline also
applies to these requested changes.
We have created the process described above to resolve all
substantive wage data correction disputes before we finalize the wage
data for the FY 1997 payment rates. Accordingly, hospitals that do not
meet the procedural deadlines set forth above will not be afforded a
later opportunity to submit wage corrections or to dispute the
intermediary's decision with respect to requested changes.
We intend to make another diskette available in mid-August that
will contain the wage data that will be used to construct the wage
index values in the final rule. As with the diskette made available in
March 1996, HCFA will make the August diskette available to hospital
associations and the public. This August diskette, however, is being
made available only for the limited purpose of identifying any
potential errors made by HCFA or the intermediary in the entry of the
final wage data that result from the process described above, not for
the initiation of new wage data correction requests. Hospitals are
encouraged to review their hospital wage data promptly after the
release of the second diskette.
If, after reviewing the August diskette, a hospital believes that
its wage data are incorrect due to a fiscal intermediary or HCFA error
in the entry or tabulation of the final wage data, it should send a
letter to both its fiscal intermediary and HCFA. The letters to the
intermediary and HCFA should outline why the hospital believes an error
exists. These requests must be received by HCFA and the intermediaries
no later than September 16, 1996. We have set this year's deadline one
week earlier than last year's deadline because we found the later
deadline made it difficult to evaluate the requests and recalculate the
wage index values before the start of FY 1997 (that is, October 1,
1996). Requests should be sent to: Health Care Financing
Administration; Office of Hospital Policy; Attention: Stephen Phillips,
Technical Advisor; Division of Prospective Payment System; C5-06-27;
7500 Security Boulevard; Baltimore, Maryland 21244-1850. The
intermediary will review requests upon receipt, and, if it is
determined that an intermediary or HCFA error exists, the fiscal
intermediary will notify HCFA immediately.
[[Page 27456]]
After mid-August, we will make changes to the hospital wage data
only in those very limited situations involving an error by the
intermediary or HCFA that the hospital could not have known about
before its review of the August diskette. Specifically, after that
point, neither the intermediary nor HCFA will accept the following
types of requests in conjunction with this process:
Requests for wage data corrections that were submitted too
late to be included in the data transmitted to the HCRIS system on or
before June 17, 1996;
Requests for correction of errors made by the hospital
that were not, but could have been, identified during the hospital's
review of the March 1996 data; or,
Requests to revisit factual determinations or policy
interpretations made by the intermediary or HCFA during the wage data
correction process.
Verified corrections to the wage index received timely (that is, by
September 16, 1996) will be effective October 1, 1996.
Again, we believe the wage data correction process described above
provides hospitals with sufficient opportunity to bring errors made
during the preparation of the Worksheet S-3 to the intermediary's
attention. Moreover, because hospitals will have access to the wage
data in mid-August, they will have the opportunity to detect any data
entry or tabulation errors made by the intermediary or HCFA before the
implementation of the FY 1997 wage index on October 1, 1996. If
hospitals avail themselves of this opportunity, the wage index
implemented on October 1 should be free of such errors. Nevertheless,
in the unlikely event that such errors should occur, we retain the
right to make midyear changes to the wage index under very limited
circumstances.
Specifically, in accordance with Sec. 412.63(s)(2), we may make
midyear corrections to the wage index only in those limited
circumstances where a hospital can show: (1) that the intermediary or
HCFA made an error in tabulating its data, and (2) that the hospital
could not have known about the error, or did not have an opportunity to
correct the error, before the beginning of FY 1997 (that is, by the
September 16, 1996 deadline). As indicated earlier, since a hospital
will have the opportunity to verify its data, and the intermediary will
notify the hospital of any changes, we do not foresee any specific
circumstances under which midyear corrections would be made. However,
should a midyear correction be necessary, the wage index change for the
affected area will be effective prospectively from the date the
correction is made.
D. Contract Labor--Costs Included in the Hospital Wage Index
Our policy concerning inclusion of contract labor costs for
purposes of calculating the wage index has evolved over the past
several years. Primarily, this has occurred as we recognized the role
of contract labor in meeting special personnel needs of many hospitals.
In addition, improvements in the wage data have allowed us to more
accurately identify contract labor costs and hours. As a result,
effective with the FY 1994 wage index, we included the costs of direct
patient care contract services in the wage index calculation. Effective
with the FY 1999 wage index, which will use data from FY 1995 cost
reports, we will begin to include the costs and hours of certain
management contract services.
In this proposed rule, we are soliciting comments from the public
regarding further expansion of the types of contract labor costs
included in the wage index. The following background discussion
provides a general overview of the issues related to including contract
labor costs in the wage index calculation. We also list nine specific
issues for which we are seeking public comment.
In the May 9, 1990 proposed rule (55 FR 19442), we reported the
results of the 1988 wage index survey which collected, among other
information, data on the costs and hours associated with direct patient
care contract labor. All prospective payment hospitals completed the
wage survey for their cost reporting periods ending in calendar year
1988. The survey data indicated that hospitals had difficulty in
tracking and recording the actual hours worked associated with the
contract labor. In addition, there were reporting inconsistencies. For
example, some hospitals inappropriately reported patient care services
furnished directly by physicians, which are not included in the wage
data because they are paid under Medicare Part B rather than Part A.
In the May 9, 1990 proposed rule, we also discussed public comments
we received in response to issues we raised related to including
contract labor costs in the wage index. Specifically, in the May 8,
1989 proposed rule (54 FR 19647), we requested comment on the following
issues:
Should the wage index include data on contract labor?
Should the definition of contract services in the wage
index survey be expanded to include services indirectly related to
patient care, such as billing or housekeeping services?
A majority of the commenters supported the inclusion of contract
services, and many argued for the expansion of contract labor services
to include indirect patient care services. Those opposed to including
contract services, in addition to some commenters who supported
including contract service costs, were concerned about the difficulty
of accurately tracking and recording hours worked for all types of
contract labor. Other commenters were also concerned that if a hospital
contracts for services from outside its labor market area, the contract
wages could artificially increase or decrease the hospital's area wage
index. Based on the comments and the overall poor quality of the 1988
survey data, we decided to exclude all contract labor from the FY 1991
wage index.
We stated that we would continue our analysis of contract labor. In
addition, we announced that we would develop a new wage index survey
with improved instructions and auditing criteria to facilitate the
inclusion of contract labor in future wage index updates. The new
survey, Worksheet S-3, Part II, was included in the hospital cost
report effective with cost reporting periods beginning on or after
October 1, 1989.
The Worksheet S-3, Part II consists of detailed information for use
in the hospital wage index including contract labor for direct patient
care services. In the instructions for completing this worksheet,
contract labor costs and hours were limited to labor-related payments
and hours attributable to direct patient care contract services, such
as nursing services. Specifically, we instructed hospitals to exclude
indirect patient care contract services (for example, management and
housekeeping services), nonlabor-related expenses (for example,
equipment and supplies), and any contract services for which labor-
related payments and hours could not be accurately determined.
In the September 4, 1990 final rule (55 FR 36036), we discussed
additional comments we received on the contract labor issue. Those
commenters who supported the inclusion of contract labor stated that
some hospitals, especially rural hospitals, are dependent on contract
labor for nursing services, and it would be unfair not to include these
wage data. Other commenters requested that the definition of contract
[[Page 27457]]
labor be expanded to include indirect patient care services.
We also received several comments requesting that we continue to
exclude contract labor from the wage index. These commenters stated
that the contract labor data are not reliable because of the difficulty
in tracking and reporting hours and the lack of consistency in the
reporting of contract labor. In addition, inclusion of nonlabor
contract costs would inappropriately drive up labor costs, and contract
labor brought in from outside the labor market area would artificially
increase or decrease the area wage index value. Finally, commenters
were concerned that contract labor costs are too variable, temporary,
and not reflective of true wage costs. Therefore, some suggested that
contract labor should not be included in the wage index.
The FY 1994 wage index, which was based on the data collected on
the Worksheet S-3, Part II, was the first to include direct patient
care contract labor costs. In making the decision to include these
costs, we analyzed hospitals' FY 1990 data to determine if it was
sufficiently complete for inclusion in the wage index calculation (see
the May 26, 1993 proposed rule (58 FR 30236)). We noted that, in most
labor market areas, including contract labor in the wage index
computation had little effect on the average hourly wage. We further
stated that, based on our analysis of the data, including direct
patient care contract labor would more accurately and fairly reflect
wage levels across hospitals and MSAs. In the September 1, 1993 final
rule, we also responded to comments from the hospital industry
expressing concern that we did not recognize the costs of certain
contract management services (58 FR 46296). In particular, many rural
hospitals stated they were either unable to recruit or afford top
managers such as hospital administrators and must contract for these
services.
In the September 1, 1994 final rule (59 FR 45355), we expanded the
definition of contract labor for purposes of determining the hospital
wage index to include the personnel costs and hours associated with
certain contract management personnel. Contract management services
would be limited to individuals working in the top four positions in
the hospital: the Chief Executive Officer/Hospital Administrator, Chief
Operating Officer, Chief Financial Officer, and Nursing Administrator.
We noted that while exact titles may vary, individuals should be
performing essentially the same duties as customarily assigned these
management positions.
We further noted that, since the cost report did not provide at
that time for the collection of management contract data, this revised
definition would not be effective until cost reporting periods
beginning on or after October 1, 1994 (FY 1995). Hospitals were
instructed to continue to exclude all management contract costs and
hours until the FY 1995 data were reported (these data will be used to
compute the FY 1999 wage index). In addition, we began requiring
hospitals to provide descriptions and aggregate totals for all
management contracts and complete details on all direct patient care
contracts on the Form HCFA-339 (the Provider Cost Report Reimbursement
Questionnaire). A hospital must file this form with its corresponding
cost report.
We continue to receive requests that we expand our contract labor
definition to include more types of contract services in the wage
index. In particular, we have been asked to include the costs for
pharmacy and laboratory services on the basis that these services are
consistent with our definition of direct patient care (see the
September 1, 1995 final rule (60 FR 45792)). Others have asked that we
expand our definition to include all contracted services, both direct
and indirect patient care services, in order to more appropriately
calculate relative hospital wage costs.
We have limited the contract services that are included in the wage
index to direct patient care services and specific management services
for several reasons. First, hospitals reported difficulty in accurately
tracking the hours associated with contract services, especially for
off-site facilities that serve more than one hospital. Second, we are
concerned about the contractor's ability to separate nonlabor costs
from labor costs. We believe that the generally higher costs for
contract labor compared to salaried labor, due at least in part to the
added costs of overhead and supplies not separately identified in most
contracts, may distort the wage index. Finally, we are concerned that
it is difficult to remove the costs and hours for services such as
legal and accounting from total management contracts.
Our goal is to ensure that our wage index policy continues to be
responsive to the changing need for contract labor, allowing those
hospitals that must depend on contract labor to supply needed services
to reflect those costs in their wage data. At the same time, however,
we wish to avoid providing an opportunity for hospitals to inflate
their average hourly wage inappropriately by including nonlabor
contract costs. The advantage of our approach of including only
contract labor costs and hours associated with direct patient care and
specific management services is that it minimizes distortions in the
wage index that are due to a hospital's inability to identify and
exclude nonlabor costs. While changes to the wage index values are made
in a budget neutral manner and are not expected to affect aggregate
payments, we strive for policies that are equitable for all hospitals.
Finally, due to the 4-year time lag between the cost reporting
period itself and the fiscal year when data for that period are used in
calculating the wage index, it is important that we anticipate any need
to change our policy on contract labor. Therefore, in order to
formulate the most responsive and responsible policy, we are soliciting
comments on the following issues:
To what extent do hospitals rely on the use of contract
services?
For which services are contracts typically used?
Can hospitals accurately determine hours related to
contract services?
Can hospitals accurately isolate labor-related costs from
nonlabor-related costs?
Should the contract labor definition be expanded to
include contract services indirectly related to patient care?
If contract labor remains limited to direct patient care,
what categories of services, if any, in addition to those identified
above, should be included?
Would the wage index more accurately reflect relative wage
levels if we did not limit contract labor to direct patient care
(generally high wage) services?
Would expanding the types of contract labor that are
included in the wage index provide less incentive to hospitals to keep
their labor costs low, as higher labor costs may result in a higher
wage index value for that hospital or allow it to reclassify to a labor
market with a higher wage index?
What other issues should be considered in revising the
policy for including contract labor in the wage index?
E. Puerto Rico Wage Index Values
For several years, hospitals in Puerto Rico have experienced large
swings in their wage index values. In the September 1, 1995 final rule,
we responded to two comments suggesting changes to the wage index for
hospitals in Puerto Rico (60 FR 45796). One suggestion was to establish
a floor for the wage index values of the Puerto Rico labor market areas
while the other was to eliminate the rural area classification in
Puerto Rico and classify the rural
[[Page 27458]]
hospitals to the nearest urban area. Although we did not adopt either
of these suggestions, we stated that we would continue to study the
issue of wage index values in Puerto Rico.
To evaluate the effect that these large changes in wage index
values have on hospitals in Puerto Rico, we examined the most recent
Medicare cost data for these hospitals. Of the 50 hospitals contained
in our data base, 64 percent had improved Medicare operating margins
from 1992 to 1993. Of the 26 hospitals with data available for 1994, we
found that 65 percent improved financially from 1993 to 1994. Based on
this analysis, we do not believe that the wage index changes have had a
detrimental effect on these hospitals as a group. However, there are
individual hospitals that are not faring as well.
We recognize that large shifts in the wage index values can cause
shifts in the payment levels for a particular MSA. Because three of the
six MSAs in Puerto Rico (Aguadilla, Arecibo, and Caguas) as well as the
rural area have four or fewer hospitals, a large change in one
hospital's wage data can cause a large increase or decrease in the wage
index value for the entire MSA. One possible method to limit these
annual swings in wage index values would be to create a single labor
market area encompassing all the hospitals in Puerto Rico. That is, the
six MSAs and the rural area would be combined into one area with one
wage index value. A single labor market area would create a much larger
set of hospitals to develop aggregate wage amounts and would mitigate
situations where a change in the wage data of a single hospital has a
large effect on the wage index of an MSA.
Because creating one MSA for Puerto Rico would be implemented in a
budget neutral manner, the effect would be to raise wage index values
for some hospitals in Puerto Rico and to lower the values for others.
Using the FY 1993 wage data, the following table shows the effect this
change would have on the proposed wage index levels.
----------------------------------------------------------------------------------------------------------------
Number of Proposed One area Percent
Area hospitals wage index wage index change
----------------------------------------------------------------------------------------------------------------
Rural....................................................... 4 0.4182 0.4555 8.92
Aguadilla................................................... 2 0.4430 0.4555 2.82
Arecibo..................................................... 2 0.4661 0.4555 -2.27
Caguas...................................................... 4 0.4638 0.4555 -1.79
Mayaguez.................................................... 5 0.4186 0.4555 8.82
Ponce....................................................... 7 0.4500 0.4555 1.22
San Juan.................................................... 29 0.4616 0.4555 -1.32
----------------------------------------------------------------------------------------------------------------
Because of the negative effects on some hospitals, we are
soliciting comment on this approach for mitigating the fluctuations in
wage index values for hospitals in Puerto Rico. The potential change
would have no impact on hospitals outside Puerto Rico.
F. Proposed Changes to the MGCRB Composition and Criteria
Under section 1886(d)(10) of the Act, the MGCRB considers
applications by hospitals for geographic reclassification for purposes
of payment under the prospective payment system. Guidelines concerning
the criteria and conditions for hospital reclassification are located
at Secs. 412.230 through 412.236. The purpose of these criteria is to
provide direction, to both the MGCRB and those hospitals seeking
geographic reclassification, with respect to the situations that merit
an exception to the rules governing the geographic classification of
hospitals under the prospective payment system. The composition of the
MGCRB and the procedures it follows in making reclassification
determinations are set forth in Secs. 412.246 through 412.280.
As discussed in detail below, we are proposing to make one change
to the MGCRB regulations. In addition, we are soliciting comments on
sources of data that could be used to identify the occupational mix in
a given MSA.
1. MGCRB Composition (Sec. 412.246)
Section 1886(d)(10)(B)(i) of the Act provides that the MGCRB is
composed of five members appointed by the Secretary. This provision is
implemented in regulations at Sec. 412.246(a). Two of the members must
be representative of the concerns of rural hospitals and at least one
member must be knowledgeable in the field of analyzing costs of
providing inpatient hospital services. Under current Sec. 412.246(b),
the term of office for an MGCRB member is 3 years, and appointments are
limited to two consecutive 3-year terms. This section further provides
that to permit staggered terms of office, initial appointments may be
for shorter terms. Finally, the Secretary is permitted to terminate a
member's tenure before his or her full term has expired.
Since the establishment of the MGCRB 6 years ago, we have never
modified the regulations that govern the MGCRB's composition, which
were originally modeled after the procedural regulations of the
Provider Reimbursement Review Board (PRRB). We believe that it is now
appropriate to update the regulations that govern members' terms of
office in light of agency experience.
Appointments to the Board must comply with statutory requirements
concerning rural representatives and a hospital cost expert. Since the
appointment of the initial Board, the Secretary has had difficulty
recruiting additional, qualified persons to serve on the MGCRB. In
addition, we solicited comment in the June 2, 1995 proposed rule (60 FR
29218) on the idea of eliminating the MGCRB and transferring its
functions back to HCFA. This may have caused qualified members to lose
interest in becoming or remaining Board members. We no longer believe
that there needs to be a limitation on the number of terms a member may
serve. Deleting the term limit requirement would allow for increased
flexibility in appointing and recruiting qualified Board members.
Flexibility in this area will allow the Secretary to ensure that Board
members are in place to meet the tight statutory deadlines associated
with filing and adjudicating MGCRB applications. (Under sections
1886(d)(10)(C) (ii) and (iii) of the Act, a hospital requesting a
change in geographic classification must submit its application to the
Board not later than the first day of the preceding fiscal year. Once
the application is received the Board must render a decision within 180
days.) Therefore, we are proposing to eliminate the current requirement
at Sec. 412.246(b) that a Board member can serve for only two
consecutive 3-year terms.
We also considered eliminating any requirement on the length of an
individual term. However, we believe that maintaining a term of office
not to exceed 3 years is appropriate. If we
[[Page 27459]]
deleted this requirement, then the Secretary could not periodically
reevaluate membership of the Board. We would, however, propose that a
term of office would not be limited only to a term of exactly 3 years.
Specifically, we would revise Sec. 412.246(b) to provide that an
appointment to the MGCRB may be for any term not to exceed 3 years. We
believe that both of these proposed changes would allow the Secretary
maximum flexibility to recruit and retain qualified Board members.
Under the proposed revisions, the Secretary would continue to be
able to terminate a member's tenure before his or her full term has
expired. This provision was modeled after the provisions of the PRRB
under which the Secretary has the authority to terminate a Board member
for good cause. We believe that it is appropriate for the Secretary to
be able to exercise a similar termination authority over the MGCRB in
case a member of the MGCRB fails to carry out his or her duties under
the Act and regulations. Therefore, we would retain this provision. We
note that the Secretary has not invoked this authority to date with
either the PRRB or the MGCRB.
2. Occupational Mix Adjustment
Section 1886(d)(10)(D)(i) of the Act requires the Secretary to
publish guidelines to be utilized by the MGCRB in rendering decisions
on applications submitted for geographic reclassification. Those are to
include guidelines for ``comparing wages, taking into account (to the
extent the Secretary determines appropriate) occupational mix, in the
area in which the hospital is classified and the area in which the
hospital is applying to be classified.''
Section 412.230(e) describes the criteria for hospital
reclassification for purposes of the wage index. One of the criteria
relates to the relationship between the hospital's wages and those of
the area to which it seeks reclassification. Specifically,
Sec. 412.230(e)(1)(iv) provides that the hospital must demonstrate that
its wages are at least 84 percent of the average hourly wage of
hospitals in the area to which it seeks reclassification, or that the
hospital's average hourly wage weighted for occupational mix is at
least 90 percent of the average hourly wage of hospitals in the area to
which it seeks reclassification. Under Secs. 412.232(c) and 412.234(b),
a group of hospitals seeking to reclassify must demonstrate that its
aggregate average hourly wage is at least 85 percent of the average
hourly wage of the hospitals in the area to which it seeks
reclassification. These sections also provide that the threshold for
occupational-mix adjusted hourly wage for hospital groups is the same
as that for a single hospital, that is, 90 percent.
In the September 6, 1990 interim final rule (55 FR 36760), we
stated that the acceptable sources for occupational mix data were the
American Hospital Association (AHA) or the Bureau of Labor Statistics.
Since publication of that document, the Bureau of Labor has
discontinued its hospital wage surveys. Thus, the only currently
acceptable occupational mix data source is the AHA Survey Data. We have
been informed by the AHA that the survey for 1993 will be the last
survey to collect information on the Hospital Personnel by Occupational
Category. Therefore, requests filed on or before October 1, 1996 for FY
1998 reclassification, which use FY 1993 wage data, may be the last for
which we have an appropriate source of occupational mix data.
As we stated in the June 4, 1991 final rule with comment period (56
FR 25458), the reclassification process requires the use of
occupational mix data that are comparable across areas and can be
consistently applied. We are unaware of any sources other than the AHA
data that meet these criteria.
We have not proposed collecting occupational mix data ourselves in
light of past experience. We attempted to collect such data some time
ago. In the September 30, 1988 Federal Register (53 FR 38495), we
reported on our efforts to collect 1986 occupational mix data as part
of the Medicare National Uniform Reporting Demonstration project, to
determine the feasibility of developing a wage index that would take
into account occupational mix. The majority of hospitals (more than 60
percent) failed to complete or submit the survey. A number of surveys
that were submitted were not filled out completely and appeared to have
numerous errors. Moreover, we believe that collecting occupational mix
data from hospitals would be inappropriately burdensome to the
hospitals. In the past, we have received several comments from
hospitals opposing HCFA's collection of occupational mix data (56 FR
43222), citing the prohibitive cost to hospitals of furnishing
occupational mix data. Finally, even if we were to decide now to begin
collecting occupational mix data, it would be at least 6 years before
the data would be available for use.
In order to continue to allow the use of wage data weighted by
occupational mix in wage index reclassification, we are seeking
suggestions about any occupational mix data sources that are available
on a national basis. In addition, we are willing to consider
suggestions about other methods that would account for occupational mix
in the wage index reclassification process.
IV. Rebasing and Revising of the Hospital Market Baskets
A. Operating Costs
1. Background
Effective for cost reporting periods beginning on or after July 1,
1979, we developed and adopted a hospital input price index (that is,
the hospital ``market basket'') for operating costs. Although ``market
basket'' technically describes the mix of goods and services used to
produce hospital care, this term is also commonly used to denote the
input price index (that is, cost category weights and price proxies
combined) derived from that market basket. Accordingly, the term
``market basket'' as used in this document refers to the hospital input
price index.
The percentage change in the market basket reflects the average
change in the price of goods and services hospitals purchase in order
to furnish inpatient care. We first used the market basket to adjust
hospital cost limits by an amount that reflected the average increase
in the prices of the goods and services used to furnish hospital
inpatient care. This approach linked the increase in the cost limits to
the efficient utilization of resources.
With the inception of the hospital inpatient prospective payment
system on October 1, 1983, we continued to use the hospital market
basket to update each hospital's 1981 inpatient operating cost per
discharge used in establishing the FY 1984 standardized payment
amounts. In addition, the projected change in the hospital market
basket has been the integral component of the update factor by which
the prospective payment rates are updated every year. Under section
1886(b)(3)(B)(i)(XII) of the Act, the prospective payment rates will be
updated in FY 1997 by the projected increase in the hospital market
basket minus 0.5 percentage points. A detailed explanation of the
hospital market basket used to develop the prospective payment rates
was published in the Federal Register on September 3, 1986 (51 FR
31461). For additional background information on general development of
hospital input price indexes, we refer the reader to the article by
Freeland, Anderson, and Schendler, ``National Hospital Input Price
Index,'' Health Care Financing Review, Summer 1979, pp 37-61. We also
refer the reader to the September 4, 1990 Federal Register (55 FR
35990) in which we discussed the previous
[[Page 27460]]
rebasing of the hospital input price index.
The hospital market basket is a fixed-weight, Laspeyres-type price
index that is constructed in three steps. First, a base period is
selected and total base period expenditures are estimated for mutually
exclusive and exhaustive spending categories based upon type of
expenditure. Then, the proportion of total costs that each category
represents is determined. These proportions are called cost or
expenditure weights. Second, each expenditure category is matched to an
appropriate price/wage variable, referred to as a price proxy. These
price proxies are price levels derived from a publicly available
statistical series published on a consistent schedule, preferably at
least on a quarterly basis. Third and finally, the price level for each
spending category is multiplied by the expenditure weight for that
category. The sum of these products (that is, the expenditure weights
multiplied by the price levels) for all cost categories yields the
composite index level in the market basket in a given year. Repeating
this step for other years produces a series of market basket index
levels over time. Dividing one index level by an earlier index level
produces rates of growth in the input price index.
The 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 of goods and services that was purchased in the
base period. The effects on total expenditures resulting from changes
in the quantity or mix of goods and services purchased subsequent to
the base period are not considered. For example, shifting a
traditionally inpatient type of care to an outpatient setting might
affect the volume of inpatient goods and services purchased by the
hospital, but would not be factored into the price change measured by a
fixed weight hospital market basket.
We believe that it is desirable to rebase the market basket
periodically so the cost weights reflect changes in the mix of goods
and services that hospitals purchase (hospital inputs) in furnishing
inpatient care. We last rebased the hospital market basket cost weights
effective for FY 1991. This market basket, still used through FY 1996,
reflected base year data from FY 1987 in the construction of the cost
weights.
In its April 1, 1985 report to the Secretary (Appendix C of the
June 10, 1985 proposed rule (50 FR 24446)), ProPAC supported HCFA's
position on periodic rebasing, stating that the market basket cost
weights should be recalculated or ``rebased'' at least every 5 years,
or more frequently if significant changes in the weights occur. We note
that there are separate market baskets for prospective payment
hospitals and hospitals and hospital units excluded from the
prospective payment system. The separate, excluded hospital market
basket is set forth in section IV.A.5 of this preamble.
2. Rebasing and Revising the Hospital Market Basket
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,
we are proposing to move the base year cost structure from FY 1987 to
FY 1992). Revising means changing data sources, cost categories, or
price proxies used in the input price index.
We are proposing to use a rebased and revised hospital market
basket in developing the FY 1997 update factor for the prospective
payment rates. The new market basket would be rebased to reflect 1992,
rather than 1987, cost data.
In developing the rebased and revised market basket, we reviewed
hospital operating expenditure data for the market basket cost
categories. In a change from previous methodology, we are relying
primarily on Medicare hospital cost report data for the proposed
rebasing. For the proposed market baskets, we used data on hospital
expenditures for four major expense categories (wages and salaries,
employee benefits, pharmaceuticals, and a residual ``all other'') from
hospital cost reporting periods beginning in FY 1992 (that is, periods
beginning on or after October 1, 1991 and before October 1, 1992). We
refer to these as PPS-9 cost reports (the 9th year of the prospective
payment system (PPS)). The market basket was previously based on 1987
expense data from the 1988 American Hospital Association (AHA) Annual
Survey.
Expenses for wages and salaries, employee benefits, and
pharmaceuticals were determined using data from PPS-9 cost reports as
reported in the Hospital Cost Report Information System (HCRIS) files.
We determined total professional fees using AHA Annual Survey data.
Total professional fees include medical and nonmedical professional
fees. Since the medical professional fees included in the compensation
of provider-based physicians is paid under Medicare Part B, we analyzed
HCRIS data to determine the professional component of provider-based
physician compensation and subtracted it from total professional fees
to obtain an estimate of nonmedical professional fees. Malpractice
insurance costs were determined using the cost share for PPS-6 (cost
reporting periods beginning in FY 1989), the last year these costs had
to be treated separately from all other administrative and general
costs, trended forward to 1992 based on the relative importance of
malpractice costs found in the previous market basket. The All Other
Expenses category was calculated in two steps. First, from PPS-9 cost
reports, total operating expenses were tabulated by subtracting
capital-related expenses, direct medical education expenses, and the
medical professional fees from total expenses. Second, we subtracted
the total of the five cost category expenses already determined from
total operating expenses to obtain the All Other Expenses category.
After totals for these main cost categories (wages and salaries,
employee benefits, professional fees, pharmaceuticals, malpractice
insurance, and all other expenses) were calculated, we then determined
the proportion each category represents of the total costs. These
proportions represent the major rebased market basket weights. The
differences between the six major categories for the proposed 1992-
based index and the previous 1987-based index are summarized in Table 1
below.
Table 1.--Comparison of 1992 and 1987 Prospective Payment Hospital
Operating Cost Categories and Weights
------------------------------------------------------------------------
Rebased 1992 1987-based
Expense categories hospital hospital
market basket market basket
------------------------------------------------------------------------
Wages and Salaries...................... 50.244 52.2
Employee Benefits....................... 11.146 9.5
Nonmedical Professional Fees............ 2.127 1.6
[[Page 27461]]
Malpractice Insurance................... 1.189 1.4
Pharmaceuticals......................... 4.162 3.9
All Other............................... 31.132 31.4
-------------------------------
Total............................... 100.000 100.0
------------------------------------------------------------------------
Note: Although we rounded the weights to the tenths decimal position in
the 1987-based market basket as published in the September 4, 1990
final rule, we are presenting the 1992 weights in greater specificity.
Table 2 sets forth the proposed market basket cost categories,
weights, and price proxies. Weights for the ``Utilities'' and the ``All
Other'' cost categories, as well as the subcategories, were determined
using the 1987 Department of Commerce's Bureau of Economic Analysis
(BEA) Input-Output Table, from which data for the hospital industry
were extracted. The BEA Input-Output database, which is updated at 5-
year intervals, was most recently described in the Survey of Current
Business, ``Benchmark Input-Output Accounts for the U.S. Economy,
1987'' (April 1994). We anticipate that the Department of Commerce will
soon release 1992 cost data for use in determining the cost weights. If
the data are released in time to be analyzed, we will use them in the
final market basket for more refined estimates of cost expenditure
weights.
We aged the 1987 cost shares to 1992 using historical price changes
between 1987 and 1992 for each category. The aged shares were
normalized to be consistent with the 1992 hospital cost report data.
Relative weights for the new base year were then calculated for various
expenditure categories. This work resulted in the identification of 26
separate cost categories in the rebased hospital market basket, two
fewer categories than were included in the 1987-based market basket.
Detailed descriptions of each category and respective price proxy are
provided in Appendix C to this proposed rule.
Table 2.--Proposed 1992-Based Prospective Payment Hospital Operating Cost Categories, Weights, and Price Proxies
----------------------------------------------------------------------------------------------------------------
Rebased
1992
Expense categories hospital Price proxy
market
basket
----------------------------------------------------------------------------------------------------------------
1. Compensation............................. 61.390 .....................................................
A. Wages and Salaries\1\................ 50.244 HCFA Occupational Wage Index.
B. Employee Benefits\1\................. 11.146 HCFA Occupational Benefits Index.
2. Professional Fees\1\..................... 2.127 ECI--Compensation for Professional, Specialty &
Technical.
3. Utilities................................ 2.469 .....................................................
A. Fuel, Oil, and Gasoline.............. 0.345 PPI Refined Petroleum Products.
B. Electricity.......................... 1.349 PPI Commercial Electric Power.
C. Natural Gas.......................... 0.670 PPI Commercial Natural Gas.
D. Water and Sewerage................... 0.106 CPI-U Water & Sewerage Maintenance.
4. Professional Liability Insurance......... 1.189 HCFA Professional Liability Insurance Premium Index.
5. All Other................................ 32.824 .....................................................
A. All Other Products................... 24.033 .....................................................
(1.) Pharmaceuticals................ 4.162 PPI Ethical (Prescription) Drugs.
(2.) Food........................... 3.459 .....................................................
a. Direct Purchase.............. 2.363 PPI Processed Foods & Feeds.
b. Contract Service............. 1.096 CPI-U Food Away From Home.
(3.) Chemicals...................... 3.795 PPI Industrial Chemicals.
(4.) Medical Instruments............ 3.128 PPI Medical Instruments & Equipment.
(5.) Photographic Supplies.......... 0.399 PPI Photographic Supplies.
(6.) Rubber and Plastics............ 4.868 PPI Rubber & Plastic Products.
(7.) Paper Products................. 2.062 PPI Converted Paper & Paperboard Products.
(8.) Apparel........................ 0.875 PPI Apparel.
(9.) Machinery and Equipment........ 0.211 PPI Machinery & Equipment.
(10.) Miscellaneous Products........ 1.074 PPI Finished Goods.
B. All Other Services................... 8.792 .....................................................
(1.) Business Services\1\........... 3.823 ECI--Compensation for Private Workers in Business
Services.
(2.) Computer Services\1\........... 1.927 AHE Computer & Data Processing Services.
(3.) Transportation Services........ 0.188 CPI-U Transportation.
(4.) Telephone Services............. 0.531 CPI-U Telephone Services.
(5.) Postage\1\..................... 0.272 CPI-U Postage.
(6.) All Other: Labor Intensive*.... 1.707 ECI--Compensation for Private Service Occupations.
(7.) All Other: Nonlabor Intensive.. 0.344 CPI-U All Items.
--------------
Total.......................... 100.000
----------------------------------------------------------------------------------------------------------------
\1\ Labor-related.
Note: Due to rounding, weights may not sum to total.
[[Page 27462]]
The 1987-based market basket included a separate Blood Services
cost category. In the 1992-based market basket, Blood Services is
contained within the Chemicals cost category. In addition, the 1987-
based cost category for Fuel Oil, Coal, etc. has been combined with the
1987-based Motor Gasoline cost category to form the 1992-based Fuel,
Oil and Gasoline cost category. Both of these changes are based on
revised cost categories from BEA. For comparison purposes, the 1987-
based cost categories are set forth in Table 3.
Table 3.--1987-Based Prospective Payment Hospital Operating Cost Categories, Weights, and Price Proxies
----------------------------------------------------------------------------------------------------------------
1987
hospital
Expense categories market Price proxy
basket
----------------------------------------------------------------------------------------------------------------
1. Compensation............................. 61.7 .....................................................
A. Wages and Salaries1.................. 52.2 HCFA Occupational Wage Index.
B. Employee Benefits1................... 9.5 HCFA Occupational Benefits Index.
2. Professional Fees1....................... 1.6 ECI--Wages & Salaries for Professional, Specialty &
Technical.
3. Utilities................................ 2.4 .....................................................
A. Fuel, Oil, Coal, etc................. 0.6 WPI Light Fuel Oils.
B. Electricity.......................... 1.1 WPI Industrial Power.
C. Natural Gas.......................... 0.3 WPI Natural Gas.
D. Motor Gasoline....................... 0.2 WPI Gasoline.
E. Water and Sewerage................... 0.0 CPI-U Water & Sewerage Maintenance.
4. Professional Liability Insurance......... 1.4 HCFA Professional Liability Insurance Premiums.
5. All Other................................ 32.8 .....................................................
A. All Other Products................... 21.8 .....................................................
(1.)Pharmaceuticals................. 3.9 WPI Prescription Drugs.
(2.) Food........................... 3.3 .....................................................
a. Direct Purchase.............. 2.1 WPI Processed Foods.
b. Contract Service............. 1.2 CPI-U Food Away From Home.
(3.) Chemicals...................... 3.1 WPI Industrial Chemicals.
(4.) Medical Instruments............ 2.7 WPI Medical Instruments & Equipment.
(5.) Photographic Supplies.......... 2.6 WPI Photographic Supplies.
(6.) Rubber and Plastics............ 2.3 WPI Rubber & Plastic Products.
(7.) Paper Products................. 1.4 PPI Converted Paper & Paperboard Products.
(8.) Apparel........................ 1.1 WPI Textile House furnishings.
(9.) Machinery and Equipment........ 0.4 WPI Machinery & Equipment.
(10.) Miscellaneous Products........ 0.8 WPI Finished Goods.
B. All Other Services................... 11.1 .....................................................
(1.) Business Services1............. 3.8 AHE Business Services.
(2.) Computer Services1............. 2.0 AHE Computer & Data Processing Services.
(3.)Transportation Services......... 1.2 CPI-U Transportation.
(4.) Telephone Services............. 1.0 CPI-U Telephone Services.
(5.) Blood Services1................ 0.6 WPI Blood & Derivatives.
(6.) Postage1....................... 0.4 CPI-U Postage.
(7.) All Other: Labor Intensive1.... 1.2 ECI--Wages and Salaries for Private Service
Occupations.
(8.) All Other: Nonlabor Intensive.. 0.8 CPI-U All Items.
-------------------------------------------------------------------
Total........................... 100.0
----------------------------------------------------------------------------------------------------------------
\1\ Labor-related.
Note: Due to rounding, weights may not sum to total.
In the September 4, 1990 final rule, for purposes of determining
the labor-related portion of the standardized amounts, we summed the
percentages of the labor-related items (that is, wages and salaries,
employee benefits, professional fees, business services, computer and
data processing, blood services, postage, and all other labor-intensive
services) in the hospital market basket. This summation resulted in a
labor-related portion of the hospital market basket of 71.4 percent and
nonlabor-related portion of 28.6 percent. Under sections 1886 (d)(2)(H)
and (d)(3)(E) of the Act, in making payments under the prospective
payment system, the Secretary estimates from time to time the
proportion of payments that are labor-related. Since October 1, 1990,
then, we have considered 71.4 percent of costs to be labor-related for
purposes of the prospective payment system.
In connection with the rebasing of the hospital market basket, we
have re-estimated the labor-related share of the standardized amounts.
Based on the relative weights described in Table 2, the labor-related
portion that is subject to hospital wage index adjustments (based on
wages and salaries, employee benefits, professional fees, business
services, computer and data processing, postage, and all other labor-
intensive services) is 71.246 percent and the nonlabor-related portion
is 28.754 percent. To implement this change, effective with discharges
occurring on or after October 1, 1996, we are proposing to recompute
the labor-related and nonlabor-related shares of the large urban and
other areas' standardized amounts used to establish the prospective
payment rates.
The amounts in Table 4 reflect the revised labor-related and
nonlabor-related portions. Due to the Bureau of Economic Analysis'
reclassification of Blood Services to Chemicals, we now allocate Blood
Services to a nonlabor cost category. We note that, although there are
revisions of the labor and nonlabor portions, due to both weight
changes and the Blood Services category change, the labor-related
portions of the rates published in Table 4 have remained essentially
the same. The
[[Page 27463]]
labor-related portion has decreased by 0.146 percentage points.
Table 4.--Labor-Related Share
------------------------------------------------------------------------
Cost category Weight
------------------------------------------------------------------------
Wages and Salaries............................................ 50.244
Employee Benefits............................................. 11.146
Professional Fees............................................. 2.127
Business Services............................................. 3.823
Computer Services............................................. 1.927
Postal Services............................................... 0.272
All Other Labor Intensive..................................... 1.707
---------
Total Labor-Related....................................... 71.246
---------
Total Nonlabor Related.................................... 28.754
------------------------------------------------------------------------
3. Selection of Price Proxies
After computing the 1992 cost weights for the rebased hospital
market basket, it is necessary to select appropriate wage and price
proxies to monitor the rate of increase for each expenditure category.
Most of the indicators are based on Bureau of Labor Statistics (BLS)
data and are grouped into one of the following BLS categories:
Producer Price Indexes--Producer Price Indexes (PPIs)
measure price changes for goods sold in other than retail markets. For
example, we used the PPI for ethical drugs, rather than the Consumer
Price Index (CPI) for prescription drugs. PPIs are preferable price
proxies for goods that hospitals purchase as inputs in producing their
outputs. The PPIs we used measure price change at the final stage of
production.
Consumer Price Indexes--Consumer Price Indexes (CPIs)
measure change in the prices of final goods and services bought by the
typical consumer. Because they may not represent the price faced by the
producer, the consumer price indexes were used if no appropriate PPI
was available, or if the expenditure was more similar to that of retail
consumers in general rather than a purchase at the wholesale level. For
example, the CPI for food purchased away from home was used as a proxy
for contracted food services.
Employment Cost Indexes--Employment Cost Indexes (ECIs)
measure the rate of change in employee wage rates and employer costs
for employee benefits per hour worked. These indexes are fixed-weight
indexes and strictly measure the change in wage rates and employee
benefits per hour. They are not affected by shifts in employment mix.
Average Hourly Earnings--Average Hourly Earnings (AHEs)
measure the rate of change of hourly earnings for various occupations
within a given industry, and, therefore, reflect a weighted
occupational mix within a particular industry. The AHE series is
calculated by dividing gross payrolls by total hours and measures
actual earnings rather than pure wage rates. It is a current-weight
series rather than a fixed-weight index and thus reflects shifts in
employment mix. An AHE rather than an ECI is used when there is no
corresponding ECI category that is an appropriate measure of growth for
a given labor category or when the ECI does not have sufficient length
of history to be useful for our purpose.
Our proposed price proxies for the rebased prospective payment
hospital market basket are shown in Table 2 above and are summarized in
Appendix C to this proposed rule.
4. The HCFA Blended Compensation Index
Compensation includes the two largest categories of the rebased
hospital market basket. Wages and salaries account for 50.244 percent
and employee benefits account for 11.146 percent of the total weight in
the prospective payment hospital market basket.
The proposed HCFA Blended Compensation Index groups hospital
occupations into nine broad categories. For eight of those occupational
groups, we believe that hospitals compete for labor generally with
employers outside the health care sector. Accordingly, we use economy-
wide employment cost indexes (ECI) as price proxies for these eight
occupational groups. In the case of compensation for nurses, as well as
for certain other health care technicians and professionals, the
hospital labor market may be predominant. However, hospitals do compete
with other industries to obtain certain skilled professional and
technical staff (for example, computer programmers). Therefore, for
professional and technical workers, we believe a price proxy that
reflects an equal blend of internal and external compensation variables
is appropriate.
Similar to the methodology used for the previous rebasing, the
weights for the nine cost categories in the occupational blend index
were derived from the 1992 Current Population Survey (CPS) produced by
BLS. Using the CPS, private hospital workers were classified into the
nine occupational categories. Private hospitals better reflect the mix
of occupations used to produce acute care services for the prospective
payment hospital input price index. Government hospitals were excluded
because their occupational mix reflects the subset of nonacute care
hospitals. Once private hospital workers were sorted by occupation into
one of the nine occupational groups, weights were estimated using the
share of wages and salaries for each of the nine occupations. These
shares formed the basis of the weights that were used for the market
basket of occupational categories.
An additional adjustment was made for contract labor costs. Rather
than treat contract labor as a distinct noncompensation cost category,
it was integrated into the occupational blend as a component of
hospitals' compensation costs for purposes of the market basket index.
Thus, contract labor is treated the same as other labor expenses.
Contract labor was allocated to the professional and technical and
service occupation categories. After adjusting the professional and
technical and service workers' shares to account for contract labor,
the weights for the nine occupational blend categories were
renormalized to equal 100.00 percent. The weights and proxies for the
nine cost categories of the HCFA Blended Wages and Salaries Index are
shown in Table 5.
Table 5.--HCFA Blended Wages and Salaries Index (Wages and Salaries Component of the 1992-Based Market Basket)
----------------------------------------------------------------------------------------------------------------
Cost category Weight Price proxy
----------------------------------------------------------------------------------------------------------------
Professional and Technical.............................................. 65.729 Equal blend of ECI for
wages and salaries of
civilian hospital workers
and ECI for wages and
salaries of professional,
specialty and technical
workers.
Managers and Administrators............................................. 9.554 ECI for wages and salaries
for executive,
administrative and
managerial workers.
Sales................................................................... 0.402 ECI for wages and salaries
for sales workers.
Clerical Workers........................................................ 12.379 ECI for wages and salaries
for administrative support
including clerical
workers.
Craft and Kindred....................................................... 1.689 ECI for wages and salaries
for precision production,
craft and repair workers.
[[Page 27464]]
Operatives Except Transport............................................. 0.437 ECI for wages and salaries
for machine operators,
assemblers and inspectors.
Transport Equipment Operatives.......................................... 0.122 ECI for wages and salaries
for transportation and
material moving workers.
Nonfarm Laborers........................................................ 0.084 ECI for wages and salaries
for handlers, equipment
cleaners, helpers and
laborers.
Service Workers......................................................... 9.606 ECI for wages and salaries
for service occupations.
---------------------------------------
Total Wages and Salaries................................................ 100.000 Total Weight for Wages and
Salaries is 50.2.
----------------------------------------------------------------------------------------------------------------
Note: Due to rounding, weights may not sum to total.
5. Separate Market Basket for Hospitals and Hospital Units Excluded
From the Prospective Payment System
In its March 1, 1990 report, ProPAC recommended that we establish a
separate market basket for hospitals and hospital units excluded from
the prospective payment system. Effective with FY 1991, HCFA adopted
ProPAC's recommendation to implement separate market baskets. (See the
September 4, 1990 final rule (55 FR 36044).) Prospective payment and
excluded hospitals tend to have different case mixes, practice
patterns, and composition of inputs. The fact that these hospitals are
not included under the prospective payment system in part reflects
these differences.
Studies completed by HCFA, ProPAC, and the hospital industry have
documented different weights for excluded hospitals and prospective
payment hospitals. Table 7 compares major weights in the rebased 1992
market basket for excluded hospitals with weights in the rebased 1992
market basket for prospective payment system hospitals. Wages and
salaries are 52.152 percent of total operating costs for excluded
hospitals compared to 50.244 percent for prospective payment hospitals.
Employee benefits are 11.569 percent for excluded hospitals compared to
11.146 percent for prospective payment hospitals. As a result,
compensation costs (wages and salaries plus employee benefits) for
excluded hospitals are 63.721 percent of costs compared to 61.390
percent for prospective payment hospitals. Noncompensation costs are
36.279 percent for excluded hospitals and 38.610 of costs for
prospective payment hospitals.
Two significant differences in the category weights occur in
Pharmaceuticals and Business Services. Pharmaceuticals represent 4.162
percent of costs for prospective payment hospitals and 3.070 percent
for excluded hospitals. Business services represent 3.823 percent of
costs for prospective payment hospitals and 2.337 percent for excluded
hospitals. The weights for the excluded hospital market basket were
derived using the same data sources and methods as for the prospective
payment market basket (see Appendix C to this proposed rule).
Differences in weights between the proposed excluded hospital and
prospective payment hospital market baskets do not necessarily lead to
significant differences in the rate of price growth for the two market
baskets. If the individual wages and prices move at the approximately
same annual rate, both market baskets may have about the same price
growth even though weights may differ substantially because both market
baskets use the same wages and prices. Also, offsetting price increases
for various cost components can result in similar composite price
growth in both market baskets.
The wage and price proxies are the same for the excluded hospital
and prospective payment hospital market baskets. As discussed in
section IV.A.2 of this preamble, all of the cost expenditure weights
for both the prospective payment and excluded hospital market baskets
are subject to refinement if the U.S. Department of Commerce data are
released in time to be analyzed and incorporated in the final market
basket.
The excluded hospital market basket is a composite set of weights
for Medicare participating psychiatric, long-term care, rehabilitation,
and children's hospitals. We are proposing to use cost report data for
excluded hospitals and units whose Medicare average length of stay is
within 15 percent (that is, 15 percent higher or lower) of the total
facility average length of stay. This is a change from the 1987-based
market basket, for which data for all excluded hospitals and units were
used. We believe that limiting our sample to hospitals with a Medicare
average length of stay within 15 percent of the total facility average
length of stay provides a more accurate reflection of the structure of
costs for Medicare. We note that the proposed forecast for FY 1997
would be the same even if we had included all excluded hospitals in the
calculation of weights. The forecast for both the limited and full set
of excluded hospitals yields a rate of change for FY 1997 of 2.7
percent.
Table 6.--Comparison of Significant Weights for 1992-Based Excluded
Hospital and Prospective Payment Hospital Market Baskets
------------------------------------------------------------------------
Prospective
Category Excluded payment
hospitals hospitals
------------------------------------------------------------------------
Wages and Salaries............................ 52.152 50.244
Employee Benefits............................. 11.569 11.146
Professional Fees............................. 2.098 2.127
Pharmaceuticals............................... 3.070 4.162
All Other..................................... 31.111 32.321
-------------------------
Total..................................... 100.000 100.000
------------------------------------------------------------------------
[[Page 27465]]
Table 7.--Proposed 1992-Based Excluded Hospital Operating Cost Categories, Weights, and Price Proxies
----------------------------------------------------------------------------------------------------------------
Rebased
1992
excluded
Expense categories hospital Price proxy
market
basket
----------------------------------------------------------------------------------------------------------------
1. Compensation............................................................ 63.721
A. Wages and Salaries.................................................. 52.152 HCFA Occupational Wage
Index.
B. Employee Benefits................................................... 11.569 HCFA Occupational
Benefits Index.
2. Professional Fees....................................................... 2.098 ECI--Compensation for
Professional, Specialty
& Technical.
3. Utilities............................................................... 2.557
A. Fuel, Oil, and Gasoline............................................. 0.357 PPI Refined Petroleum
Products.
B. Electricity......................................................... 1.396 PPI Commercial Electric
Power.
C. Natural Gas......................................................... 0.694 PPI Commercial Natural
Gas.
D. Water and Sewerage.................................................. 0.110 CPI-U Water & Sewerage
Maintenance.
4. Professional Liability Insurance........................................ 1.081 HCFA Professional
Liability Insurance
Premiums Index.
5. All Other............................................................... 30.543
A. All Other Products.................................................. 23.642
(1.) Pharmaceuticals............................................... 3.070 PPI Ethical
(Prescription) Drugs.
(2.) Food.......................................................... 3.581
a. Direct Purchase............................................. 2.446 PPI Processed Foods &
Feeds.
b. Contract Service............................................ 1.135 CPI-U Food Away From
Home.
(3.) Chemicals..................................................... 3.929 PPI Industrial
Chemicals.
(4.) Medical Instruments........................................... 3.238 PPI Medical Instruments
& Equipment.
(5.) Photographic Supplies......................................... 0.413 PPI Photographic
Supplies.
(6.) Rubber and Plastics........................................... 5.039 PPI Rubber & Plastic
Products.
(7.) Paper Products................................................ 2.134 PPI Converted Paper &
Paperboard Products.
(8.) Apparel....................................................... 0.906 PPI Apparel.
(9.) Machinery and Equipment....................................... 0.218 PPI Machinery &
Equipment.
(10.) Miscellaneous Products....................................... 1.112 PPI Finished Goods.
B. All Other Services.................................................. 6.901
(1.) Business Services............................................. 2.337 ECI--Compensation for
Private Workers in
Business Services.
(2.) Computer Services............................................. 1.415 AHE Computer & Data
Processing Services.
(3.) Transportation Services....................................... 0.195 CPI-U Transportation.
(4.) Telephone Services............................................ 0.549 CPI-U Telephone
Services.
(5.) Postage....................................................... 0.282 CPI-U Postage.
(6.) All Other: Labor Intensive.................................... 1.767 ECI--Compensation for
Private Service
Occupations.
(7.) All Other: Nonlabor Intensive................................. 0.356 CPI-U All Items.
-----------
Total.......................................................... 100.000
----------------------------------------------------------------------------------------------------------------
Note: Due to rounding, weights may not sum to total.
Table 8, below, shows what the excluded hospital weights would be
if cost data for all excluded hospitals had been used.
Table 8.--1992 excluded hospital operating cost categories, weights, and proxies using data from all excluded
hospitals
----------------------------------------------------------------------------------------------------------------
Rebased 1992
excluded
Expense categories hospital Price proxy
market basket
----------------------------------------------------------------------------------------------------------------
1. Compensation........................... 68.074 ....................................................
A. Wages and Salaries................. 55.714 HCFA Occupational Wage Index.
B. Employee Benefits.................. 12.360 HCFA Occupational Benefits Index.
2. Professional Fees...................... 2.073 ECI--Compensation for Professional, Specialty &
Technical.
3. Utilities.............................. 2.191 ....................................................
A. Fuel, Oil, and Gasoline............ 0.306 PPI Refined Petroleum Products.
B. Electricity........................ 1.196 PPI Commercial Electric Power.
C. Natural Gas........................ 0.595 PPI Commercial Natural Gas.
D. Water and Sewerage................. 0.094 CPI-U Water & Sewerage Maintenance.
4. Professional Liability Insurance....... 1.081 HCFA Professional Liability Insurance Premiums
Index.
5. All Other.............................. 26.582 ....................................................
A. All Other Products................. 20.333 ....................................................
(1.) Pharmaceuticals.............. 2.704 PPI Ethical (Prescription) Drugs.
(2.) Food......................... 3.069 ....................................................
a. Direct Purchase............ 2.096 PPI Processed Foods & Feeds.
b. Contract Service........... 0.973 CPI-U Food Away From Home.
(3.) Chemicals.................... 3.367 PPI Industrial Chemicals.
(4.) Medical Instruments.......... 2.775 PPI Medical Instruments & Equipment.
[[Page 27466]]
(5.) Photographic Supplies........ 0.354 PPI Photographic Supplies.
(6.) Rubber and Plastics.......... 4.319 PPI Rubber & Plastic Products.
(7.) Paper Products............... 1.829 PPI Converted Paper & Paperboard Products.
(8.) Apparel...................... 0.777 PPI Apparel.
(9.) Machinery and Equipment...... 0.187 PPI Machinery & Equipment.
(10.) Miscellaneous Products...... 0.953 PPI Finished Goods.
B. All Other Services................. 6.248 ....................................................
(1.) Business Services............ 2.337 ECI--Compensation for Private Workers in Business
Services.
(2.) Computer Services............ 1.213 AHE Computer & Data Processing Services.
(3.) Transportation Services...... 0.167 CPI-U Transportation.
(4.) Telephone Services........... 0.471 CPI-U Telephone Services.
(5.) Postage...................... 0.242 CPI-U Postage.
(6.) All Other: Labor Intensive... 1.514 ECI--Compensation for Private Service Occupations.
(7.) All Other: Nonlabor Intensive 0.305 CPI-U All Items.
---------------------------------------------------------------------
Total......................... 100.000
----------------------------------------------------------------------------------------------------------------
The relatively small differences in weights between the proposed
excluded hospital market basket data from excluded hospitals that have
a Medicare length of stay within 15 percent of the total facility
average length of stay and the excluded hospital market basket using
data from all excluded hospitals do not lead to significant changes in
the rate of price growth for these two market baskets. If all
individual wages and prices move at about the same annual rate, both
market baskets could have about the same price growth even if weights
are somewhat different. Also, offsetting price increases for various
costs components can result in the price growth being the same.
To examine the sensitivity of the change to the limited set of
excluded hospitals, we developed a comparison for the period 1988-1998.
Using historical data and forecasts for the market baskets, we compared
limited and full sets of excluded hospitals.
Table 9.--A Comparison of the Proposed Excluded Hospital Market Basket
and the Excluded Hospital Market Basket Rebased Using All Excluded
Hospitals, Percent Change, 1988-1998
------------------------------------------------------------------------
Proposed
excluded (+/- Excluded
15%) hospital market
Federal fiscal year hospital basket using Difference
market all excluded
basket--1992 hospitals--1992
base base
------------------------------------------------------------------------
Historical:
1988....................... 4.8 4.8 0.0
1989....................... 5.5 5.5 0.0
1990....................... 4.5 4.6 (0.1)
1991....................... 4.3 4.4 (0.1)
1992....................... 3.1 3.2 (0.1)
1993....................... 3.1 3.2 (0.1)
1994....................... 2.6 2.7 (0.1)
1995....................... 3.3 3.2 0.1
Forecasted:
1996....................... 2.6 2.6 0.0
1997....................... 2.7 2.7 0.0
1998....................... 2.9 2.9 0.0
Historical average:
1988-1995.................. 3.9 4.0 (0.1)
Forecasted average:
1996-1998.................. 2.7 2.7 0.0
------------------------------------------------------------------------
Note that the historical average rate of growth for 1988-1995 for
the proposed excluded hospital market basket including only excluded
hospitals with Medicare average length of stay within 15 percent of
total facility average length of stay is virtually identical to that
for the excluded hospital market basket with all excluded hospitals.
The rates of growth using the two methodologies are identical for FY
1996, 1997, and 1998.
B. Capital Costs
Rebasing the Capital Input Price Index
1. Background
Effective for cost reporting periods beginning on or after October
1, 1995, the Capital Input Price Index (CIPI) is used to determine the
price increase associated with prospective payment hospital capital-
related expenses. Capital-related expenses are defined as depreciation
expenses, capital-related interest expenses, and other capital-related
expenses, such as insurance and taxes. The CIPI measures the input
price change of these capital-related expenses, and is included in the
capital prospective payment update framework to determine a rate of
increase in capital prospective payments.
Like the prospective payment hospital operating input price index,
the CIPI is a fixed-weight price index. A fixed-weight price index
measures how much it would cost at a later date to purchase the same
mix of goods and services purchased in the base period. For the
prospective payment hospital operating and capital input price indexes,
the base period is selected and cost category weights are determined
using available data on hospitals. Next, appropriate price proxy
indexes are chosen for each cost category. Then a price proxy index
level for each expenditure category is multiplied by the comparable
cost category weight. The sum of these products (that is, weights
multiplied by price proxy index levels) for all cost categories yields
the composite index level of the market basket for a given
[[Page 27467]]
year. Repeating the step for other years produces a time series of
composite market basket index levels. Dividing an index level by a
later index level produces a rate of growth in the input price index.
Since the percent change is computed for the fixed mix of total capital
inputs with a 1992 base, the index is called fixed-weight.
Like the operating input price index, the CIPI measures the price
changes associated with costs during a given year. In order to do so,
the CIPI must differ from the operating input price index in one
important aspect. The CIPI must reflect the vintage nature of capital,
which is the acquisition and use of capital over time. Capital expenses
in any given year are determined by the stock of capital in that year
(that is, capital that remains on hand from all current and prior
capital acquisitions). An index measuring capital price changes needs
to reflect this vintage nature of capital. Therefore, the CIPI was
developed to capture the vintage nature of capital by using a weighted-
average of past capital purchase prices up to and including the current
year. Using Medicare cost reports, AHA data, and Securities Data
Corporation data, a vintage-weighted price index was developed to
measure price increases associated with capital expenses. The most
recent discussion on the CIPI and methodological background was
published in the September 1, 1995 final rule (60 FR 45817). The
following Federal Register documents describe development and revisions
of the methodology involved with the construction of the CIPI:
September 1, 1992 (57 FR 40016), May 26, 1993 (58 FR 30448),
September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876),
September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), and
September 1, 1995 (60 FR 45815).
We periodically update the base year for the operating and capital
input prices to reflect the changing composition of inputs for
operating and capital expenses. Currently, both the operating input
price index and the CIPI are based to FY 1987. We are proposing that
the base year cost structure be updated to FY 1992, the most recent
year with relatively complete data for purposes of rebasing. We explain
the process of rebasing the cost structure weights for the CIPI below.
2. Rebasing the Capital Input Price Index
We are proposing to use a rebased capital input price index (CIPI)
in developing the FY 1997 capital update factor for capital prospective
payment rates. The new CIPI would be rebased to reflect the 1992,
rather than the 1987, structure of capital costs. In developing the
rebased CIPI, we reviewed hospital capital expenditure data for capital
cost categories (depreciation, interest, and other). Two sets of
weights had to be developed in order to compute the rebased CIPI: (1)
cost category weights which identify the proportion of total hospital
capital expenditures attributable to each capital expenditure category,
and (2) relative vintage weights for depreciation and interest which
identify the proportion of capital expenditures within a cost category
that are attributable to each year over the life of capital assets in
that category. Because capital expense data in the Medicare Cost
Reports is not available prior to 1980 for use in computing vintage
weights, the two sets of weights are measured using the best data
sources available as explained below and in Appendix C to this proposed
rule. The computations involved with rebasing the CIPI are explained
for each of these sets of weights.
a. Capital Cost Category Weights. The capital cost category weights
in Table 1 below were computed using a combination of the FY 1992
Medicare Cost Reports and 1992 AHA Annual Survey data. Fiscal Year 1992
marked the first year for expanded capital data available in the
Medicare Cost Reports. After reviewing the data, we determined that
much of the data had been reclassified into different expense
categories. Therefore, we removed reports that appeared to have
reclassified data, and matched the remaining reports to the
corresponding reports in the AHA Annual Survey data set. These
remaining 2724 reports were used to compute capital cost category
weights and the expected life of capital, which is used in determining
vintage weights for depreciation and interest.
In reviewing the data, we determined that the Medicare Cost Reports
provided accurate data for depreciation and other capital expenses, but
had reclassified interest data. We determined that AHA Annual Survey
data more accurately reflected interest expense, based on past trends
in interest rates. Therefore, we used the AHA Annual Survey interest
levels along with the Medicare Cost Report levels for depreciation and
other capital expenses to develop a more robust capital cost data base.
After removing depreciation, interest, and other capital expenses
from total capital expenses, the remainder constitutes lease expenses.
Lease expenses are not a separate cost category in the CIPI. They are
distributed to the other cost categories (depreciation, interest,
other), reflecting an assumption that the underlying cost structure of
leases is similar to capital costs in general. We assigned 10 percent
of lease expenses to the other capital expenses cost category as
overhead, and the remaining lease expenses were distributed to the
three cost categories based on the weights of depreciation, interest,
and other capital expenses not including lease expenses. (We base this
assignment of 10 percent of lease expenses to overhead on the common
assumption that overhead is 10 percent of costs.)
We also used the 1992 Medicare Cost Reports to determine weights
for the building and fixed equipment category and the movable equipment
category. Expenses for building and fixed equipment and for movable
equipment were determined using the same sample of reports as was used
to compute the major cost category weights. The split between building
and fixed equipment and movable equipment was also used to compute the
vintage weights described below. Table 10 presents a comparison of the
rebased 1992 capital cost weights and the 1987 capital cost weights.
We only used those hospital reports which we considered to have
capital data that was not reclassified. Because we did not use all
hospital reports, we were concerned that the hospitals used may not be
representative of the universe. Therefore, we compared the distribution
of costs for the hospitals used with the data re-weighted to reflect
the characteristics of the total universe of hospitals. From this
analysis we validated that the cost weights derived from the subset we
used were representative of the cost weights for the entire universe of
hospitals.
[[Page 27468]]
Table 10--Comparison of 1987 and 1992 Cost Category Weights
----------------------------------------------------------------------------------------------------------------
Rebased
Expense categories FY1987 FY1992 Price proxy
----------------------------------------------------------------------------------------------------------------
Total......................................... 1.0000 1.0000 ......................................
Total depreciation............................ .6510 .6484 ......................................
1. Building and fixed equipment .3054 .3009 Boeckh Institutional Construction
depreciation. Index--vintage weighted (22 yrs)
2. Movable equipment depreciation......... .3456 .3475 PPI for Machinery and Equipment--
vintage weighted (10 yrs)
Total interest................................ .3274 .3184
1. Government/Non Profit Interest......... .2783 .2706 Average Yield on Domestic Municipal
Bonds (Bond Buyer 20 bonds)--vintage
weighted (22 yrs)
2. For-Profit Interest.................... .0491 .0478 Average Yield on Moody's AAA Bonds--
vintage weighted (22 yrs)
Other......................................... .0216 .0332 CPI (U) for Residential Rent
----------------------------------------------------------------------------------------------------------------
Source: 1992 Medicare Cost Reports, PPS year 9; 1992 AHA Annual Survey.
Note: Due to rounding, weights may not sum to totals.
We had planned to incorporate the 1992 data from the Department of
Commerce for developing capital cost category weights. However, these
data were not available when we developed this proposed rule. If the
data become available in time to for us to analyze it, we plan to
incorporate it as a data input for the final rule.
b. Relative Vintage Weights for Prices. As we have explained in
previous Federal Register documents (September 1, 1995, 60 FR 45817),
the CIPI was developed to capture the vintage nature of capital; that
is, because capital is acquired and consumed over time, the capital
expenses in any given year are determined by past and current purchases
of physical and financial capital. Therefore, a vintage-weighted CIPI
was developed which used vintage weights for depreciation (physical
capital) and interest (financial capital) to capture the long-term
consumption of capital. These vintage weights reflect the purchase
patterns of building and fixed equipment and movable equipment over
time. Because depreciation and interest expenses are determined by the
amount of past and current capital purchases, we use the vintage
weights to compute vintage-weighted price changes associated with
depreciation and interest expense, which is the purpose of the CIPI.
To compute the vintage weights for depreciation and interest
expenses, we used a time series of capital purchases for building and
fixed equipment and movable equipment. We found no single source that
provides the best time series of capital purchases by hospitals for all
of the above components of capital purchases. The Medicare Cost Reports
did not have sufficient capital data to meet this need. The AHA Panel
Survey provides a consistent database back to 1963. While the AHA Panel
Survey data does not provide annual capital purchases, it does provide
a time series of depreciation and interest expenses, which can be used
to infer capital purchases over time. The process of using the AHA data
to estimate a time series of capital purchases, and eventually vintage
weights, is explained in detail below.
In order to estimate capital purchases from AHA data on
depreciation and interest expenses, the expected life for building and
fixed equipment, for movable equipment, and for debt instruments is
needed. The expected life is used in the calculation of vintage weights
for building and fixed equipment, movable equipment, and debt
instruments as we explain below.
We used the same sample of hospitals from FY 1992 Medicare Cost
Reports and the 1992 AHA Annual Survey explained above in computing
cost category weights to compute the expected life of building and
fixed equipment and movable equipment. (The AHA Panel Survey is a
monthly survey of a sample of hospitals, while the AHA Annual Survey is
a more detailed survey of all hospitals.) The expected life of any
piece of equipment can be determined by dividing the historical asset
cost (excluding fully depreciated assets) by the current year
depreciation amount. This calculation yields the estimated useful life
of an asset if depreciation continued at current year levels, assuming
straight-line depreciation, which is the only depreciation method
allowed under Medicare. From the FY 1992 costs reports, the expected
life of building and fixed equipment was determined to be 22 years, and
the expected life of movable equipment was determined to be 10 years.
By comparison, the expected life using FY 1987 data was 25 years for
building and fixed equipment and 10 years for movable equipment.
It was also necessary to compute the expected life of debt
instruments held by hospitals. As in prior exercises, we used hospital
issuances of municipal and commercial bonds from Securities Data
Corporation to determine the expected life of hospital debt
instruments, which is used in the estimation of vintage weights for
interest expense. This data source produced a weighted average life for
the two types of bonds of 22 years for FY 1992, the same expected life
as was computed for the 1987-based CIPI.
An annual series of total expenses and depreciation expenses was
obtained from the AHA Panel Survey. For the calculation of vintage
weights, this expense data was needed back to 1963. However, the
depreciation expense data in the AHA Panel survey was available only
back to 1976. We noticed an increasing trend in depreciation expenses
as a percentage of total expenses. We performed a regression on this
percentage, and used the regression equation to estimate depreciation
expenses back to 1963. We then used the fixed and movable weights
derived from the FY 1992 Medicare Cost Reports to partition the AHA
Panel Survey depreciation expenses into annual amounts of building and
fixed depreciation and movable depreciation.
Multiplying the annual depreciation amounts by the expected life
calculations from the FY 1992 Medicare cost reports, year-end asset
costs for building and fixed equipment and movable equipment were
determined. Then by subtracting the previous year asset costs from the
current year asset costs, annual purchases of building and fixed
equipment and movable equipment were estimated back to 1963. This
capital purchase time series is then used to compute the vintage
weights for building and fixed equipment, movable equipment, and debt
instruments. Each of these sets of vintage weights is explained in
detail below.
For building and fixed equipment vintage weights, the real annual
capital purchase amounts for building and fixed equipment derived from
the AHA Panel Survey were used. The real annual purchase amount was
used to capture the actual amount of the physical acquisition, net of
the effect of price inflation. This real annual purchase amount for
building and fixed equipment was produced by deflating
[[Page 27469]]
the nominal annual purchase amount by the building and fixed equipment
price proxy, the Boeckh institutional construction index. Because
building and fixed equipment has an expected life of 22 years, the
vintage weights for building and fixed equipment were deemed to
represent the average purchase pattern of building and fixed equipment
over 22-year periods. With real building and fixed equipment purchase
estimates available back to 1963, nine 22-year periods could be
averaged to determine the average vintage weights for building and
fixed equipment. Averaging different periods produces vintage weights
that are representative of average building and fixed equipment
purchase patterns over time. Vintage weights for each 22-year period
are calculated by dividing the real building and fixed capital purchase
amount in any given year by the total amount of purchases in the 22-
year period. For example, for the 22-year period of 1964-1985, the
vintage weight for year 1 is calculated by dividing the real annual
capital purchase amount of building and fixed equipment in 1964 into
the total amount of real annual capital purchases of building and fixed
equipment over the entire 1964-1985 period. This calculation is done
for each year in the 22-year period, and for each of the nine 22-year
periods. An average is taken of the nine 22-year periods to determine
the FY 1992 average building and fixed equipment vintage weights,
presented in Table 11 with the FY 1987 vintage weights.
For movable equipment vintage weights, the real annual capital
purchase amounts for movable equipment derived from the AHA Panel
Survey were used. The real annual purchase amount was used to capture
the actual amount of the physical acquisition, net of price inflation.
This real annual purchase amount for movable equipment was produced by
deflating the nominal annual purchase amount by the movable equipment
price proxy, the Producer Price Index for machinery and equipment.
Because movable equipment has an expected life of 10 years, the vintage
weights for movable equipment were deemed to represent the average
purchase pattern of movable equipment over 10-year periods. With real
movable equipment purchase estimates available back to 1963, 21 10-year
periods could be averaged to determine the average vintage weights for
movable equipment. Averaging different periods produces vintage weights
which are representative of average movable equipment purchase patterns
over time. Vintage weights for each 10-year period are calculated by
dividing the real movable capital purchase amount for any given year by
the total amount of purchases in the 10-year period. For example, for
the 10-year period of 1976-1985, the vintage weight for year 1 is
calculated by dividing the real annual capital purchase amount of
movable equipment in 1976 into the total amount of real annual capital
purchases of movable equipment over the entire 1976-1985 period. This
calculation is done for each year in the 10-year period, and for each
of the 21 10-year periods. The average of the 21 10-year periods is
used to determine the FY 1992 average movable equipment vintage
weights, presented in Table 11 with the FY 1987 vintage weights.
For interest vintage weights, the nominal annual capital purchase
amounts for total equipment (building and fixed, and movable) derived
from the AHA Panel Survey were used. Nominal annual purchase amounts
were used to capture the value of the debt instrument. Because debt
instruments have an expected life of 22 years, the vintage weights for
interest were deemed to represent the average purchase pattern of total
equipment over 22-year periods. With nominal total equipment purchase
estimates available back to 1963, nine 22-year periods could be
averaged to determine the average vintage weights for interest.
Averaging different periods produces vintage weights which are
representative of average capital purchase patterns over time. Vintage
weights for each 22-year period are calculated by dividing the nominal
total capital purchase amount for any given year by the total amount of
purchases in the 22-year period. For example, for the 22-year period of
1964-1985, the vintage weight for year 1 is calculated by dividing the
nominal annual capital purchase amount of total equipment in 1964 into
the total amount of nominal annual capital purchases of total equipment
over the entire 1964-1985 period. This calculation is done for each
year in the 22-year period, and for each of the nine 22-year periods.
The average of the nine 22-year periods is used to determine the FY
1992 average interest vintage weights, presented in Table 11 with the
FY 1987 weights.
Table 11.--Vintage Weights for Capital-Related Price Proxies
----------------------------------------------------------------------------------------------------------------
Building and fixed Movable equipment Interest
equipment ---------------------------------------------------
--------------------------
Year Rebased FY1987 10 Rebased FY1987 22 Rebased
FY1987 25 FY1992 22 yrs FY1992 10 yrs FY1992 22
yrs yrs yrs yrs
----------------------------------------------------------------------------------------------------------------
1................................. .015 .019 .064 .069 .007 .007
2................................. .019 .020 .072 .075 .009 .008
3................................. .022 .023 .077 .083 .010 .010
4................................. .024 .026 .085 .091 .011 .012
5................................. .023 .028 .095 .097 .013 .014
6................................. .022 .030 .101 .103 .015 .016
7................................. .020 .031 .109 .109 .017 .018
8................................. .021 .032 .122 .115 .020 .021
9................................. .025 .036 .132 .124 .023 .024
10................................ .030 .039 .142 .133 .027 .029
11................................ .033 .043 ........... ........... .032 .035
12................................ .034 .047 ........... ........... .038 .041
13................................ .034 .050 ........... ........... .043 .047
14................................ .035 .052 ........... ........... .050 .052
15................................ .038 .055 ........... ........... .057 .059
16................................ .043 .059 ........... ........... .064 .067
17................................ .049 .062 ........... ........... .074 .074
18................................ .053 .065 ........... ........... .083 .081
19................................ .056 .067 ........... ........... .090 .088
[[Page 27470]]
20................................ .057 .069 ........... ........... .098 .093
21................................ .060 .072 ........... ........... .105 .099
22................................ .066 .073 ........... ........... .114 .103
23................................ .071 ........... ........... ........... ........... ...........
24................................ .075 ........... ........... ........... ........... ...........
25................................ .077 ........... ........... ........... ........... ...........
-----------------------------------------------------------------------------
Total....................... 1.000 1.000 1.000 1.000 1.000 1.000
----------------------------------------------------------------------------------------------------------------
Sources: AHA Panel Survey, 1963-1993; 1992 Medicare Cost Reports; Securities Data Corporation.
3. Selection of Price Proxies
After the 1992 capital cost category weights were computed, it was
necessary to select appropriate price proxies to monitor the rate of
increase for each expenditure category. Our proposed price proxies for
the FY 1992 based CIPI are the same as those for the FY 1987 based
CIPI. The rationale for selecting the price proxies is explained in the
June 2, 1995 proposed rule (60 FR 29227) and the September 1, 1995
final rule (60 FR 45817). The proposed price proxies are presented in
Table 10.
4. Forecast of the CIPI for Federal Fiscal Year 1997
DRI forecasts a 1.0 percent increase in the rebased 1992 CIPI for
FY 1997, as indicated in Table 12. This is the outcome of a 2.5 percent
increase in projected depreciation prices (building and fixed
equipment, and movable equipment) and a 2.3 percent increase in other
capital expense prices in FY 1997, partially offset by a 3.0 percent
decline in vintage-weighted interest rates in FY 1997.
Table 12.--HCFA Capital Input Price Index Percent Changes, Total and Components, Fiscal Years 1979 to 2000
----------------------------------------------------------------------------------------------------------------
Depreciation
---------------------------------------
Fiscal Year Total Building Interest Other
Total and fixed Movable
equipment equipment
----------------------------------------------------------------------------------------------------------------
Weights (FY92).................... 1.0000 0.6484 0.3009 0.3475 0.3184 0.0332
----------------------------------------------------------------------------------------------------------------
Price Changes
----------------------------------------------------------------------------------------------------------------
1979.............................. 5.4 7.4 7.0 7.7 2.7 7.1
1980.............................. 6.9 8.0 7.3 8.5 5.4 8.6
1981.............................. 8.7 8.5 7.7 9.1 9.1 8.8
1982.............................. 9.2 8.5 8.0 9.0 10.2 8.0
1983.............................. 6.7 8.1 7.9 8.2 4.8 6.3
1984.............................. 6.3 7.3 7.6 7.1 4.9 5.0
1985.............................. 5.2 6.3 7.0 5.8 3.5 5.9
1986.............................. 3.7 5.7 6.4 5.1 0.7 6.2
1987.............................. 3.1 5.1 5.9 4.5 -0.1 4.5
1988.............................. 3.0 4.6 5.4 4.0 0.3 3.8
1989.............................. 2.6 4.4 5.2 3.7 -0.5 3.8
1990.............................. 2.3 4.0 4.9 3.2 -0.7 4.2
1991.............................. 2.0 3.6 4.6 2.7 -1.1 3.9
1992.............................. 1.5 3.2 4.4 2.1 -2.0 2.6
1993.............................. 1.1 2.9 4.1 1.8 -2.8 2.4
1994.............................. 1.1 2.7 3.9 1.7 -2.7 2.3
1995.............................. 1.3 2.6 3.8 1.6 -2.0 2.5
1996.............................. 0.9 2.5 3.7 1.5 -3.1 2.4
1997.............................. 1.0 2.5 3.5 1.5 -3.0 2.3
1998.............................. 1.0 2.5 3.4 1.5 -3.1 3.0
1999.............................. 1.0 2.4 3.4 1.5 -3.1 2.4
2000.............................. 1.1 2.4 3.4 1.5 -3.2 2.8
----------------------------------------------------------------------------------------------------------------
Source: DRI/McGraw-Hill HCC, 1st Qtr 1996; @USSIM/TREND25YR0296 @CISSIM/CONTROL961.
Released By: HCFA, OACT, Office of National Health Statistics.
[[Page 27471]]
5. Comparison of Percent Changes in the FY 1992 Based CIPI and the FY
1987 Based CIPI
Rebasing the CIPI from 1987 to 1992 decreased the percent change in
the FY 1997 forecast by only 0.2 percentage points, from 1.2 to 1.0 as
indicated in Table 4. The effect of rebasing is analyzed by comparing
the 1992-based CIPI forecasted percent changes to the 1987-based CIPI
forecasted percent changes using the same DRI forecast of component
prices. As shown in Table 13, there is only a 0.2 percentage point
difference between the percent changes in the 1992-based CIPI and the
1987-based CIPI using the first quarter 1996 forecast. The difference
is caused by changes to: (1) cost category weights, (2) expected life,
and (3) vintage weights. The changes to cost category weights coupled
with the wide disparity in price changes between the different cost
categories contributed to lowering the CIPI percent change in the FY
1997 forecast. This was the case with fixed depreciation, which has
faster price growth than the other cost categories and now has a lower
weight by nearly one-half of a percentage point because of rebasing to
1992. Also contributing to the 0.2 percentage point difference in FY
1997 forecast is the change in the expected life of building and fixed
equipment and the change in the vintage weights for all three
components: building and fixed equipment, movable equipment, and
interest. The shorter expected life (22 years in 1992 versus 25 years
in 1987) of building and fixed equipment slightly decreased the FY 1997
forecast CIPI percent change because years with higher price increases
were not included as they had been before. The change in vintage
weights also tended to decrease the FY 1997 CIPI percent change because
vintage weights in all cases changed to be spread more evenly over the
life of the asset, decreasing the weight of more recent years and
increasing the weight of past years. In the years around FY 1997,
prices for depreciation and interest are projected to increase slightly
faster than prices in earlier years.
Table 13.--Comparison of 1987 and 1992 Based Capital Input Price Index
Using the Same DRI Forecast, Percent Change, 1979-1997
------------------------------------------------------------------------
CIPI
-------------------
Federal fiscal year Rebased
1987 1992
------------------------------------------------------------------------
1979................................................ 5.6 5.4
1980................................................ 7.1 6.9
1981................................................ 8.8 8.7
1982................................................ 9.3 9.2
1983................................................ 6.7 6.7
1984................................................ 6.3 6.3
1985................................................ 5.1 5.2
1986................................................ 3.7 3.7
1987................................................ 3.1 3.1
1988................................................ 3.0 3.0
1989................................................ 2.7 2.6
1990................................................ 2.4 2.3
1991................................................ 2.1 2.0
1992................................................ 1.7 1.5
1993................................................ 1.3 1.1
1994................................................ 1.3 1.1
1995................................................ 1.5 1.3
1996................................................ 1.2 0.9
1997................................................ 1.2 1.0
------------------------------------------------------------------------
Source: DRI/McGraw-Hill HCC, 1st Qtr 1996; @USSIM/TREND25YR0296 @CISSIM/
CONTROL961.
Released by: HCFA, OACT, Office of National Health Statistics.
6. Comparison of Percent Changes in the FY 1997 CIPI Forecast in the
September 1, 1995 Federal Register and the current FY 1997 CIPI
Forecast
The previously published CIPI forecast for FY 1997 of 1.7 percent
has been revised to 1.0 percent in this proposed rule. As explained
above in section IV.B.5, 0.2 percentage points of the decline was the
result of rebasing the CIPI from 1987 to 1992. The remaining 0.5
percentage point difference in FY 1997 between the 1992-based CIPI and
the 1987-based CIPI previously published is the result of revised
projections by DRI. Since making a forecast in the second quarter of
1995 for the September 1, 1995 Federal Register, DRI has revised their
projections of price changes downward for every cost category in the
CIPI. This revised projection accounts for 0.5 of the 0.7 difference
between the 1992-based CIPI percent changes and the 1987-based CIPI
percent changes previously published.
V. Other Decisions and Proposed Changes to the Prospective Payment
System for Inpatient Operating Costs
A. Sole Community Hospital Criteria (Sec. 412.92)
Under the prospective payment system, special payment protections
are provided to hospitals that, by reason of factors such as isolated
location, weather conditions, travel conditions, or absence of other
hospitals, are the sole source of hospital inpatient services
reasonably available to Medicare beneficiaries. The criteria a hospital
must meet to be classified as a sole community hospital (SCH) as well
as the special payment adjustments available are set forth in the
regulations at Sec. 412.92.
One of the ways in which a hospital can qualify for sole community
status is to be located between 25 and 35 miles from other like
hospitals and prove that no more than 25 percent of residents who
become inpatients or no more than 25 percent of the Medicare
beneficiaries who become inpatients in the hospital's ``service area''
are admitted to other like hospitals located within a 35-mile radius of
the hospital (or its service area, if larger).
In the rulemaking process for FY 1989, we addressed the criteria
for qualification as a sole community hospital. ProPAC had recommended
that we issue guidelines before the beginning of FY 1989 to promote
greater uniformity in the criteria applied by regional offices to
designate sole community hospitals. In the final rule published on
September 30, 1988, we stated: ``A hospital may delineate its service
area by identifying the zip codes of all its inpatients for the cost
reporting period ending before the date it applies for SCH status. The
lowest number of zip codes accounting for at least 75 percent of its
inpatients would then constitute its service area.'' (53 FR 35810-11).
In March 1990, we issued a revised manual which inadvertently
reflected policy prior to October 1, 1988; specifically, section 2810
A.2.c of the Medicare Provider Reimbursement Manual, Part 1 (HCFA Pub.
15-1) stated, ``A hospital may define its service area as the lowest
number of contiguous zip codes from which the hospital draws at least
75 percent of its inpatients.'' (Emphasis added.) This revision does
not accurately reflect the definition of ``service area'' that we set
forth in the FY 1989 final rule in response to ProPAC's recommendation
that we address the criteria for SCH status. It has come to our
attention that, accordingly, some hospitals have raised questions about
the definition of service area. In this proposed rule, we are
clarifying that, consistent with the language in the September 30, 1988
final rule, our definition of ``service area'' for purposes of
determining SCH status does not require contiguous zip code areas. We
have applied this definition since October 1, 1988 (the effective date
of the September 30, 1988 final rule). The
[[Page 27472]]
current manual inadvertently reflects previous policy, and does not
reflect our current policy as set forth in the Federal Register and
applied since October 1, 1988. We intend to revise the current manual
accordingly at our earliest opportunity.
B. Rural Referral Centers (Sec. 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act,
Sec. 412.96 sets forth the criteria a hospital must meet in order to
receive special treatment under the prospective payment system as a
rural referral center. For discharges occurring before October 1, 1994,
rural referral centers received the benefit of payment based on the
other urban rather than the rural standardized amount. As of that date,
the other urban and rural standardized amounts are the same. However,
rural referral centers continue to receive special treatment under both
the disproportionate share hospital payment adjustment and the criteria
for geographic reclassification.
One of the criteria under which a rural hospital may qualify as a
referral center is to have 275 or more beds available for use. A rural
hospital that does not meet the bed size criterion can qualify as a
rural referral center if the hospital meets two mandatory criteria
(number of discharges and case-mix index) and at least one of three
optional criteria (medical staff, source of inpatients, or volume of
referrals). With respect to the two mandatory criteria, a hospital may
be classified as a rural referral center if its--
Case-mix index is at least equal to the lower of the
median case-mix index for urban hospitals in its census region,
excluding hospitals with approved teaching programs, or the median
case-mix index for all urban hospitals nationally; and
Number of discharges is at least 5,000 discharges per year
or, if fewer, the median number of discharges for urban hospitals in
the census region in which the hospital is located. (The number of
discharges criterion for an osteopathic hospital is at least 3,000
discharges per year.)
1. Case-Mix Index
Section 412.96(c)(1) provides that HCFA will establish updated
national and regional case-mix index values in each year's annual
notice of prospective payment rates for purposes of determining rural
referral center status. In determining the proposed national and
regional case-mix index values, we follow the same methodology we used
in the November 24, 1986 final rule, as set forth in regulations at
Sec. 412.96(c)(1)(ii). Therefore, the proposed national case-mix index
value includes all urban hospitals nationwide, and the proposed
regional values are the median values of urban hospitals within each
census region, excluding those with approved teaching programs (that
is, those hospitals receiving indirect medical education payments as
provided in Sec. 412.105).
These values are based on discharges occurring during FY 1995
(October 1, 1994 through September 30, 1995) and include bills posted
to HCFA's records through December 1995. Therefore, in addition to
meeting other criteria, we are proposing that to qualify for initial
rural referral center status or to meet the triennial review standards
for cost reporting periods beginning on or after October 1, 1996, a
hospital's case-mix index value for FY 1995 would have to be at least--
1.3332; or
Equal to the median case-mix index value for urban
hospitals (excluding hospitals with approved teaching programs as
identified in Sec. 412.105) calculated by HCFA for the census region in
which the hospital is located.
The median case-mix values by region are set forth in the table
below:
------------------------------------------------------------------------
Case-mix
Region index
value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................... 1.2292
2. Middle Atlantic (PA, NJ, NY)............................... 1.2224
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)........ 1.3375
4. East North Central (IL, IN, MI, OH, WI).................... 1.2450
5. East South Central (AL, KY, MS, TN)........................ 1.2911
6. West North Central (IA, KS, MN, MO, NE, ND, SD)............ 1.2178
7. West South Central (AR, LA, OK, TX)........................ 1.3080
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY).................. 1.3284
9. Pacific (AK, CA, HI, OR, WA)............................... 1.3333
------------------------------------------------------------------------
The above numbers will be revised in the final rule to the extent
required to reflect the updated MedPAR file, which will contain data
from additional bills received for discharges through September 30,
1995.
For the benefit of hospitals seeking to qualify as referral centers
or those wishing to know how their case-mix index value compares to the
criteria, we are publishing each hospital's FY 1995 case-mix index
value in Table 3C in section V of the Addendum to this proposed rule.
In keeping with our policy on discharges, these case-mix index values
are computed based on all Medicare patient discharges subject to DRG-
based payment.
2. Discharges
Section 412.96(c)(2)(i) provides that HCFA will set forth the
national and regional numbers of discharges in each year's annual
notice of prospective payment rates for purposes of determining
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. However, we
are proposing to update the regional standards. The proposed regional
standards are based on discharges for urban hospitals' cost reporting
periods that began during FY 1994 (that is, October 1, 1993 through
September 30, 1994). That is the latest year for which we have complete
discharge data available.
Therefore, in addition to meeting other criteria, we are proposing
that to qualify for initial rural referral center status or to meet the
triennial review standards for cost reporting periods beginning on or
after October 1, 1996, the number of discharges a hospital must have
for its cost reporting period that began during FY 1995 would have to
be at least--
5,000; or
Equal to the median number of discharges for urban
hospitals in the census region in which the hospital is located, as
indicated in the table below.
------------------------------------------------------------------------
Number of
Region discharges.
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................... 6812
2. Middle Atlantic (PA, NJ, NY)............................ 9067
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 6972
4. East North Central (IL, IN, MI, OH, WI)................. 6958
5. East South Central (AL, KY, MS, TN)..................... 5007
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 4216
7. West South Central (AR, LA, OK, TX)..................... 4002
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 6992
9. Pacific (AK, CA, HI, OR, WA)............................ 5669
------------------------------------------------------------------------
We reiterate that, to qualify for rural referral center status for
cost reporting periods beginning on or after October 1, 1996, an
osteopathic hospital's number of discharges for its cost reporting
period that began during FY 1995 would have to be at least 3,000.
3. Retention of Referral Center Status
Section 412.96(f) states that each hospital receiving the referral
center adjustment is reviewed every 3 years to
[[Page 27473]]
determine if the hospital continues to meet the criteria for referral
center status. To retain status as a referral center, a hospital must
meet the criteria for classification as a referral center specified in
Sec. 412.96 (b)(1) or (b)(2) or (c) for 2 of the last 3 years, or for
the current year. A hospital may meet any one of the three sets of
criteria for individual years during the 3-year period or the current
year. For example, a hospital may meet the two mandatory requirements
in Sec. 412.96(c)(1) (case-mix index) and (c)(2) (number of discharges)
and the optional criterion in paragraph (c)(3) (medical staff) during
the first year. During the second or third year, the hospital may meet
the criteria under Sec. 412.96(b)(1) (rural location and appropriate
bed size).
A hospital must meet all of the criteria within any one of these
three sections of the regulations in order to meet the retention
requirement for a given year. That is, it will have to meet all of the
criteria of Sec. 412.96(b)(1) or Sec. 412.96(b)(2) or Sec. 412.96(c).
For example, if a hospital meets the case-mix index standards in
Sec. 412.96(c)(1) in years 1 and 3 and the number of discharge
standards in Sec. 412.96(c)(2) in years 2 and 3, it will not meet the
retention criteria. All of the standards would have to be met in the
same year.
In accordance with Sec. 412.96(f)(2), the review process is limited
to the hospital's compliance during the last 3 years. Thus, if a
hospital meets the criteria in effect for at least 2 of the last 3
years or if it meets the criteria in effect for the current year (that
is, the criteria for FY 1997 outlined above in this section of the
preamble), it will retain its status for another 3 years. We have
constructed the following chart and example to aid hospitals that
qualify as referral centers under the criteria in Sec. 412.96(c) in
projecting whether they will retain their status as a referral center.
Under Sec. 412.96(f), to qualify for a 3-year extension effective
with cost reporting periods beginning in FY 1997, a hospital must meet
the criteria in Sec. 412.96(c) for FY 1997 or it must meet the criteria
for 2 of the last 3 years as follows:
----------------------------------------------------------------------------------------------------------------
Use the discharges
for the hospital's Use numerical standards as
For the cost reporting period Use hospital's case- cost reporting published in the Federal
beginning during FY mix index for FY period beginning Register on
during FY
----------------------------------------------------------------------------------------------------------------
1996.............................. 1994................. 1994................ September 1, 1995.
1995.............................. 1993................. 1993................ September 1, 1994.
1994.............................. 1992................. 1992................ September 1, 1993.
----------------------------------------------------------------------------------------------------------------
Example: A hospital with a cost reporting period beginning July
1 qualified as a referral center effective July 1, 1994. The
hospital has fewer than 275 beds. Its 3-year status as a referral
center is protected through June 30, 1997 (the end of its cost
reporting period beginning July 1, 1996). To determine if the
hospital should retain its status as a referral center for an
additional 3-year period, we will review its compliance with the
applicable criteria for its cost reporting periods beginning July 1,
1994, July 1, 1995, and July 1, 1996. The hospital must meet the
criteria in effect either for its cost reporting period beginning
July 1, 1997, or for two out of the three past periods. For example,
to be found to have met the criteria at Sec. 412.96(c) for its cost
reporting period beginning July 1, 1995, the hospital's case-mix
index value during FY 1993 must have equaled or exceeded the lower
of the national or the appropriate regional standard as published in
the September 1, 1994 final rule with comment period. The hospital's
total number of discharges during its cost reporting year beginning
July 1, 1993, must have equaled or exceeded 5,000 or the regional
standard as published in the September 1, 1994 final rule with
comment period.
For those hospitals that seek to retain referral center status by
meeting the criteria of Sec. 412.96(b)(1) (i) and (ii) (that is, rural
location and at least 275 beds), we will look at the number of beds
shown for indirect medical education purposes (as defined at
Sec. 412.105(b)) on the hospital's cost report for the appropriate
year. We will consider only full cost reporting periods when
determining a hospital's status under Sec. 412.96(b)(1)(ii). This
definition varies from the number of beds criterion used to determine a
hospital's initial status as a referral center because we believe it is
important for a hospital to demonstrate that it has maintained at least
275 beds throughout its entire cost reporting period, not just for a
particular portion of the year.
C. Disproportionate Share Adjustment (Sec. 412.106)
Section 1886(d)(5)(F) of the Act provides for additional payments
for hospitals that serve a disproportionate share of low income
patients. The disproportionate share adjustment, which was added to the
prospective payment system by section 9105 of the Consolidated Omnibus
Budget Reconciliation Act of 1985 (Public Law 99-272), was intended to
address the higher Medicare costs associated with treating a large
number of low-income patients. Under this provision, patients who are
eligible for Medicaid and Supplemental Security Income (SSI) benefits
were used as a proxy measure of the proportion of low-income patients.
A hospital's disproportionate share adjustment is determined by
calculating the sum of two patient percentages (Medicare Part A/
Supplemental Security Income (SSI) covered days to total Medicare Part
A covered days, and Medicaid but not Medicare Part A covered days to
total inpatient hospital days). Based on the location and size of the
hospital, a formula determines if the hospital's patient percentage
qualifies the hospital for an adjustment and how much that adjustment
will be.
With respect to the Medicare-SSI calculation, hospitals have
expressed dissatisfaction with these proxy measures, and have
challenged HCFA's implementation of them in recent litigation. Since
SSI beneficiary information is confidential, hospitals do not have
access to lists of patients who are eligible for both Medicare Part A
and SSI benefits. Hospitals are increasingly frustrated by their
inability to monitor these data.
With respect to the Medicaid fraction, hospitals have complained
that, because of Medicaid coverage restrictions, Medicaid covered days
may not be a consistent measure of indigent care across States.
Medicaid reforms under consideration by the President and Congress may
further interfere with the utility of Medicaid covered days as a
measure of the proportion of low-income patients.
Because of these concerns, we have been examining alternative
measures of indigent care. Some of the measures we have explored using
are estimates of patient income in a hospital's service area, hospital
levels of bad debt, and proportion of emergency room admissions in a
hospital. Because of data and other limitations, however, we have yet
to find an alternative that appears promising as a replacement to
[[Page 27474]]
the present measure. We are, therefore, soliciting comments from the
industry on better and more direct measures of indigent care than the
present measure that relies on SSI and Medicaid data. Our preference
would be to use data that are already available. We would, however, be
open to considering measures that require new data collection if we
were convinced that the result would be beneficial to hospitals and
HCFA. We note that since HCFA is bound by the current statutory
provisions, we cannot revise the disproportionate share adjustment
without legislative action.
We note that ProPAC is also concerned with these issues. In its
March 1, 1996 report, ProPAC recommended that the structure of the
disproportionate share adjustment be reviewed to make certain that
available funds are distributed equitably among the hospitals most in
need of assistance. (Recommendation 18.) The Commission believes that
Medicaid utilization has never been an optimal measure of service to
low-income patients and is also concerned with the impact of possible
reform in the structure of Medicaid. Thus, ProPAC recommends that a
comprehensive review of the disproportionate share adjustment be
undertaken, including assessment of the objectives of this payment and
defining the population and scope of care to be covered. Alternative
measures of low-income patient care could then be considered, including
any data collection necessary. As discussed above, we agree with ProPAC
that new measures should be explored. We believe that this is a first
step in reforming the payment formula for the disproportionate share
adjustment. We also recognize that the development of a better measure
of the services hospitals provide to indigent patients may require the
collection of new data.
In addition, ProPAC is concerned about the potential impact of
reductions in the disproportionate share payments. (Recommendation 17.)
The Commission believes that hospitals that treat a large number of the
uninsured could be particularly vulnerable because of recent changes in
the health care environment. ProPAC cautions against large reductions
in disproportionate share payments that would threaten the continued
ability of many hospitals to serve populations who depend on them for
access to care. We note that the President's FY 1997 budget does not
include any reduction in payment for disproportionate share hospitals.
D. Direct Graduate Medical Education (Sec. 413.86)
1. Initial Residency Period Limitations
We are updating the Initial Residency Period Limitations for direct
graduate medical education (GME), originally published in the Federal
Register on September 29, 1989 (54 FR 40286). The regulations in
Sec. 413.86(g)(1) state that, ``[e]ffective July 1, 1995, an initial
residency period is defined as the minimum number of years required for
board eligibility.''
The update reflects the following:
Effective July 1, 1995, section 1886(h)(5)(F) of the Act,
as amended by Public Law 103-66, defines an initial residency period as
the minimum number of years required for initial board eligibility.
Previously, this period had been defined as minimum number of years
``plus one.'' The prior listing had included the additional year, not
to exceed five years.
Changes in curriculum requirements regarding the number of
years needed for board eligibility for previously approved programs.
Addition of newly approved graduate medical education
programs.
Initial Residency Period Limitations
------------------------------------------------------------------------
Initial
Residency
Residency type Period
Limitation
(No. of years)
------------------------------------------------------------------------
Allopathy
ANESTHESIOLOGY.......................................... 4
Critical Care Medicine.............................. 4
Pain Management..................................... 4
COLON AND RECTAL SURGERY................................ 5
DERMATOLOGY............................................. 4
Dermatopathology.................................... 4
Clinical & Laboratory Dermatological Immunology..... 4
EMERGENCY MEDICINE...................................... 3/4
Sports Medicine..................................... 3
FAMILY PRACTICE......................................... 3
Geriatric Medicine.................................. 5
Sports Medicine..................................... 3
INTERNAL MEDICINE....................................... 3
Adolescent Medicine................................. 3
Cardiovascular Disease.............................. 3
Clinical Cardiac Electrophysiology.................. 3
Clinic & Laboratory Immunology...................... 3
Critical Care Medicine.............................. 3
Endocrinology, Diabetes, and Metabolism............. 3
Gastroenterology.................................... 3
Geriatric Medicine.................................. 5
Hematology.......................................... 3
Hematology and Oncology............................. 3
Infectious Disease.................................. 3
Medical Oncology.................................... 3
Nephrology.......................................... 3
Pulmonary Disease................................... 3
Pulmonary Disease and Critical Care Medicine........ 3
Rheumatology........................................ 3
Sports Medicine..................................... 3
MEDICAL GENETICS........................................ 4
[[Page 27475]]
NEUROLOGICAL SURGERY.................................... 5
Pediatric Neurological Surgery...................... 5
NEUROLOGY............................................... 4
Child Neurology..................................... 4
Clinical Neurophysiology............................ 4
NUCLEAR MEDICINE........................................ 3
OBSTETRICS AND GYNECOLOGY............................... 4
Critical Care Medicine.............................. 4
Gynecological Oncology.............................. 4
Maternal and Fetal Medicine......................... 4
Reproductive Endocrinology.......................... 4
OPHTHALMOLOGY........................................... 4
ORTHOPAEDIC SURGERY..................................... 5
Adult Reconstructive Orthopaedics................... 5
Foot and Ankle Orthopaedics......................... 5
Hand Surgery........................................ 5
Musculoskeletal Oncology............................ 5
Pediatric Orthopaedics.............................. 5
Spinal Cord Injury.................................. 5
Sports Medicine..................................... 5
OTOLARYNGOLOGY.......................................... 5
Neurotology/Otolaryngology.......................... 5
Pediatric Otolaryngology............................ 5
PATHOLOGY, ANATOMIC AND CLINICAL........................ 4
Blood Banking/Transfusion Medicine.................. 4
Chemical Pathology.................................. 4
Cytopathology....................................... 4
Dermatopathology.................................... 4
Forensic Pathology.................................. 4
Hematology.......................................... 4
Immunopathology..................................... 4
Medical Microbiology................................ 4
Neuropathology...................................... 4
Pediatric Pathology................................. 4
PEDIATRICS.............................................. 3
Adolescent Medicine................................. 3
Clinical and Laboratory Immunology.................. 3
Neonatal-Perinatal Medicine......................... 3
Pediatric Cardiology................................ 3
Pediatric Critical Care Medicine.................... 3
Pediatric Emergency Medicine........................ 3
Pediatric Endocrinology............................. 3
Pediatric Gastroenterology.......................... 3
Pediatric Hematology/Oncology....................... 3
Pediatric Infectious Disease........................ 3
Pediatric Nephrology................................ 3
Pediatric Opthamology............................... 3
Pediatric Pulmonology............................... 3
Pediatric Rheumatology.............................. 3
Pediatric Sports Medicine........................... 3
PHYSICAL MEDICINE AND REHABILITATION.................... 4
PLASTIC SURGERY......................................... 5
Hand Surgery........................................ 5
PREVENTIVE MEDICINE..................................... 3
Aerospace Medicine.................................. 3
Medical Toxicology.................................. 3
Occupational Medicine............................... 3
Public Health & General Preventive Medicine......... 3
PSYCHIATRY.............................................. 4
Addiction Medicine.................................. 4
Child & Adolescent Psychiatry....................... 4
Forensic Psychiatry................................. 4
Geriatric Psychiatry................................ 4
RADIOLOGY, DIAGNOSTIC................................... 4
Neuroradiology...................................... 4
Nuclear Radiology................................... 4
Pediatric Radiology................................. 4
Vascular and Interventional Radiology............... 4
Radiation Oncology.................................. 4
[[Page 27476]]
SURGERY, GENERAL........................................ 5
Critical Care Medicine.............................. 5
Hand Surgery........................................ 5
Pediatric Surgery................................... 5
Thoracic Surgery.................................... 5
Vascular Surgery.................................... 5
UROLOGY................................................. 5
Pediatric Urology................................... 5
Osteopathy
ANESTHESIOLOGY.......................................... 4
Critical Care Medicine.............................. 4
DERMATOLOGY............................................. 4
Dermatopathology.................................... 4
MOHS Micrographic Surgery........................... 4
EMERGENCY MEDICINE...................................... 4
Sports Medicine..................................... 4
FAMILY PRACTICE......................................... 3
Adolescent and Young Adult Medicine................. 3
Geriatrics.......................................... 5
Sports Medicine..................................... 3
INTERNAL MEDICINE....................................... 4
Clinical Allergy and Immunology..................... 4
Cardiology.......................................... 4
Endocrinology....................................... 4
Gastroenterology.................................... 4
Hematology.......................................... 4
Infectious Diseases................................. 4
Nephrology.......................................... 4
Oncology............................................ 4
Pulmonary Diseases.................................. 4
Rheumatology........................................ 4
Clinical Cardiac Electrophysiology.................. 4
Critical Care Medicine.............................. 4
Geriatrics.......................................... 6
Sports Medicine..................................... 4
NUCLEAR MEDICINE........................................ 4
In-Vivo and In-Vitro Nuclear Medicine............... 4
Nuclear Cardiology.................................. 4
Nuclear Imaging and Therapy......................... 4
NEUROLOGY............................................... 4
Child Neurology..................................... 4
PSYCHIATRY.............................................. 4
Child Psychiatry.................................... 4
OBSTETRICS/GYNECOLOGY................................... 5
Maternal and Fetal Medicine......................... 5
Gynecological Oncology.............................. 5
Reproductive Endocrinology.......................... 5
FACIAL PLASTIC SURGERY.................................. 5
OPHTHALMOLOGY........................................... 4
OTORHINO/FACIAL PLASTIC SURGERY......................... 5
OTORHINOLARYNGOLOGY..................................... 5
ORTHOPEDIC SURGERY...................................... 5
PATHOLOGY, ANATOMIC..................................... 4
PATHOLOGY, ANATOMIC/LABORATORY MEDICINE................. 5
PATHOLOGY, LABORATORY MEDICINE.......................... 4
Forensic Pathology.................................. 5
Blood Banking/Transfusion Medicine.................. 5
Chemical Pathology.................................. 5
Cytopathology....................................... 5
Dermatopathology.................................... 5
Hematology.......................................... 5
Immunopathology..................................... 5
Medical Microbiology................................ 5
Neuropathology...................................... 5
PEDIATRICS.............................................. 3
Adolescent and Young Adult Medicine................. 3
Neonatal Medicine................................... 3
Pediatric Allergy/Immunology........................ 3
Pediatric Cardiology................................ 3
[[Page 27477]]
Pediatric Hematology/Oncology....................... 3
Pediatric Infectious Diseases....................... 3
Pediatric Intensive Care............................ 3
Pediatric Nephrology................................ 3
Pediatric Pulmonology............................... 3
Pediatric Sports Medicine........................... 3
PREVENTATIVE MEDICINE................................... 4
PROCTOLOGY.............................................. 3
RADIATION ONCOLOGY...................................... 4
RADIOLOGY, DIAGNOSTIC................................... 5
Angiography and Interventional Radiology............ 5
Diagnostic Ultrasound............................... 5
Neuroradiology...................................... 5
Nuclear Radiology................................... 5
Radiological Imaging................................ 5
Pediatric Radiology................................. 5
REHABILITATION MEDICINE................................. 4
Sports Medicine..................................... 4
GENERAL SURGERY......................................... 5
NEUROSURGERY............................................ 5
PLASTIC AND RECONSTRUCTIVE SURGERY...................... 5
THORACIC CARDIOVASCULAR SURGERY......................... 5
UROLOGICAL SURGERY...................................... 5
GENERAL VASCULAR SURGERY................................ 5
CRITICAL CARE SURGERY................................... 5
OSTEOPATHIC MANIPULATIVE MEDICINE....................... 3
Podiatry
ROTATING PODIATRIC RESIDENCY (PRIMARY CARE)............. 2
PODIATRIC ORTHOPEDIC RESIDENCY.......................... 2
PODIATRIC SURGICAL RESIDENCY............................ 2
Dentistry
DENTAL PUBLIC HEALTH.................................... 1
ENDODONTICS............................................. 2
ORAL PATHOLOGY.......................................... 3
ORAL AND MAXILLOFACIAL SURGERY.......................... 4
ORTHODONTICS............................................ 2
PEDIATRIC DENTISTRY..................................... 2
PERIODONTICS............................................ 3
PROSTHODONTICS.......................................... 3
PROSTHODONTICS/MAXILLOFACIAL............................ 3
GENERAL DENTISTRY....................................... 1
ADVANCED GENERAL DENTISTRY.............................. 2
Allopathy Combined Programs *
FAMILY PRACTICE(3) AND PSYCHIATRY(4).................... 4
INTERNAL MEDICINE(3) & EMERGENCY MEDICINE(3)............ 3
INTERNAL MEDICINE(3) & FAMILY PRACTICE(3)............... 3
INTERNAL MEDICINE(3) & NEUROLOGY(4)..................... 4
INTERNAL MEDICINE(3) & PEDIATRICS(3).................... 3
INTERNAL MED(3) & PHYS MED & REHABILITATION(4).......... 4
INTERNAL MEDICINE(3) & PREVENTIVE MEDICINE(3)........... 3
INTERNAL MEDICINE(3) & PSYCHIATRY(4).................... 4
NEUROLOGY(4) & PHYS MEDICINE AND REHAB(4)............... 4
PEDIATRICS(3) & EMERGENCY MEDICINE(3)................... 3
PEDIATRICS(3) & PHYSICAL MEDICINE AND REHAB(4).......... 4
PEDIATRICS(3)/PSYCHIATRY(4)/CHILD & ADOL PSYCH(4)....... 4
PSYCHIATRY(4) AND NEUROLOGY(4).......................... 4
------------------------------------------------------------------------
* For residents participating in combined programs, Medicare limits the
initial residency period to the time required for individual
certification in the longer of the two programs.
2. Combined Residency Programs
While updating the listing of the Initial Residency Period
Limitations for GME, we noted many new programs were combined specialty
residency programs. The combined programs run concurrently for a period
of time that is longer than the required time for certification in
either specialty, but shorter than would be required if the programs
were taken sequentially. Residents completing these programs are
eligible for board certification in both specialties.
We use the Internal Medicine and Pediatrics combined program as an
example: Taken individually, Internal Medicine is a 3-year program and
Pediatrics is also a 3-year program. However, taken as a combined
program, Internal Medicine and Pediatrics is a 4-
[[Page 27478]]
year program, with certification in both specialties.
Currently, we are aware of 13 combined programs, including Internal
Medicine/Pediatrics, Pediatrics/Emergency Medicine, Family Practice/
Psychiatry, and Neurology/Physical Medicine and Rehabilitation.
Due to the increasing prevalence of combined residency programs
since our September 29, 1989 final rule, we propose to clarify how the
definition of initial residency period applies in such cases. While the
combined programs may have advantages from an educational standpoint,
the statutory limitation on payment for GME still applies. In the
initial legislation for a per resident payment to hospitals for GME,
Congress limited Medicare's liability for those payments to residents
in their initial residency period plus one year. The plus-one-year
provision allowed for payment for an additional year as a full FTE for
residents who continued on in a second approved program after
completing their initial certification. However, regardless of the
number of additional years the second program required for
certification, at most only the first year could be paid as a full FTE.
All subsequent years are paid at a 0.5 FTE rate. When Congress revised
section 1886(h) of the Act to remove the plus-one-year provision,
Congress further restricted payment to allow payment as a full FTE for
the first residency program only. All years of a subsequent program are
now limited to the 0.5 FTE rate. Congress clearly wanted to further
limit Medicare's payment obligations. Accordingly, we believe that the
initial residency period limitation is designed to allow full Medicare
payment only for the period required to train in one specialty.
For residents enrolled in combined programs, we are therefore
proposing to define the initial residency period as the time required
for individual certification in the longer of the two programs.
Continuing to use Internal Medicine and Pediatrics as an example, we
would define the initial residency for Internal Medicine and Pediatrics
as 3 years. The remaining year of the combined program would be treated
as 0.5 FTE, in accordance with the regulations at Sec. 413.86(g)(3).
E. Distribution of an ``Important Message from Medicare'' (Sec. 489.27)
Under Sec. 489.27 of our provider agreement regulations, all
hospitals that participate in Medicare (including those not paid under
the prospective payment system) must agree to furnish each Medicare
beneficiary with a notice, at or about the time of admission, that
explains the patient's discharge rights. This statement, entitled ``An
Important Message from Medicare,'' advises a beneficiary of his or her
rights to be fully informed about decisions affecting Medicare coverage
or payment and about his or her appeal rights in response to any
hospital's notice to the effect that Medicare will no longer cover the
patient's care. The ``Important Message'' also advises the patient of
what to do when he or she receives such a hospital statement and how to
elicit more information.
In November 1993, the Medicare Technical Advisory Group (M-TAG)
established the Beneficiary Protection and Documentation Issues Task
Force. The task force consists of HCFA staff as well as representatives
from health care industry organizations, beneficiary advocate groups,
fiscal intermediaries, and peer review organizations (PROs). The task
force was charged with reviewing various issues that impact
beneficiaries and the health care community, including how to improve
the effectiveness of ``An Important Message from Medicare.''
We are proposing to adopt a recommendation of this task force that
would respond to numerous requests for clarification on the timing of
the written notice of discharge rights that must be given to hospital
inpatients. As noted above, existing Sec. 489.27 specifies that a
hospital must distribute the statement ``at or about the time of
admission.'' We understand that for monitoring purposes some PROs have
interpreted this requirement to mean ``within 24 hours preceding or
following the admission.'' However, we agree with the task force's
determination that the PRO's interpretation is unnecessarily narrow. We
believe that during the first 24 hours of a patient's admission, the
hospital is primarily concerned with ensuring appropriate treatment of
the patient's illness or injury. Therefore, we are proposing to change
Sec. 489.27 to specify that the hospital must provide timely notice
during the course of the hospital stay.
For purposes of this requirement, we would consider the course of
the hospital stay to begin when the hospital provides the individual
with a package of information regarding scheduled preadmission testing
and registration for a planned hospital admission. This would give
hospitals more flexibility in meeting the requirement, as well as
encourage the distribution of the ``Important Message'' at a time when
the beneficiary is better able to receive and more likely to understand
its contents. In complying with the requirement to provide timely
notice during the course of the patient's hospital stay, the hospital
must give the patient the ``Important Message'' far enough in advance
of the hospital's written notice regarding continued stay to provide
the beneficiary time to appeal the hospital's decision. Finally,
``timely notice'' would also include adherence to any State
requirements on the provision of patient rights notices.
The current version of the ``Important Message'' has been in use
since 1988. As part of our effort to improve communication with
Medicare beneficiaries, we will continue to evaluate the effectiveness
of the ``Important Message'' and welcome suggestions for its
improvement.
VI. Changes and Clarifications to the Prospective Payment System for
Capital-Related Costs
A. Consistent Cost Finding During the Capital Transition Period (Sec.
412.302(d))
Section 412.302(d) of the regulations requires that, during the
transition period to full prospective payment for capital-related
costs, a hospital must follow consistent cost-finding methods for
classifying and allocating capital-related costs. Specifically, the
regulation requires that unless there is a change of ownership, a
hospital must continue the same cost-finding methods for old capital
costs, including its practices for direct assignment of costs and its
cost-allocation bases, that were in effect in the hospital's last cost-
reporting period before becoming subject to payment under the capital
prospective payment transition system. A hospital may request a change
in its cost-finding methods for new capital, provided that the request
is made in a timely fashion as provided in the regulation, the hospital
provides justification for the change, and the intermediary determines
that the justification is reasonable.
It is important to note that, while the regulation does permit
changes in cost-finding methods for new capital, such changes are only
permitted where they do not involve any changes in cost-finding for old
capital. In practice, this means that if a hospital claims any old
capital, the intermediary cannot permit a change in any of the
allocation bases on Worksheet B-1 of the cost report from the bases
used in the last cost reporting period prior to the capital prospective
payment system transition period. Otherwise, the consistency rule
governing old capital cost-finding would be violated.
As we discussed in the preamble to the August 30, 1991 final rule
for the capital prospective payment system (56
[[Page 27479]]
FR 43396), our primary reason for establishing this consistency rule
was to prevent hospitals from using changes in cost-finding
methodologies to shift costs to areas where payment continues to be
made on a reasonable cost basis. Allowing changes in cost-finding
methodologies to accomplish such cost-shifting would obviously defeat
the purpose of adopting a prospective payment system.
In response to concerns expressed by the hospital industry about
the costs of the recordkeeping required under the cost-reporting rules,
HCFA has developed new cost reporting instructions, which will be
released later this year, that permit hospitals to voluntarily adopt a
simplified cost allocation methodology. This methodology reduces the
number of statistical bases that a hospital is required to maintain.
Under the new instructions for HCFA Form 2552-96 (the cost report
instructions for FY 1996 cost reporting periods), hospitals may request
the simplified cost allocation methodology. However, hospitals that
elect this methodology must employ a prescribed list of statistical
bases with no deviations. Hospitals may not pick and choose among the
prescribed statistics for the combination that is most advantageous.
Furthermore, a hospital that elects the simplified methodology must
continue to use it for at least 3 years, unless a change of ownership
occurs. We expect that, while election of the simplified method will
always result in reduced recordkeeping costs for the hospital, it will
also result frequently in reduced Medicare payment for the hospital. In
fact, the instructions for HCFA Form 2552-96 will caution hospitals to
compare the reduced costs of program compliance with the reduced costs
of the simplified recordkeeping before electing the simplified method.
We believe this proposal to permit election of the simplified cost
allocation methodology, as provided in the instructions for HCFA Form
2552-96, reasonably reconciles concerns about recordkeeping costs with
the requirement of consistent cost-finding during the transition.
Specifically, we propose to add a new paragraph (d)(4) to Sec. 412.302,
to provide that, hospitals may elect to adopt the simplified cost
allocation methodology, as will be provided in the instructions for
HCFA Form 2552-96.
B. Possible Adjustments to the Capital Prospective Payment System
Federal Rate and Hospital-Specific Rates (Secs. 412.308(b) and 412.328)
In the proposed and final rules for FY 1996 (60 FR 29238-29239 and
60 FR 45830-45831), we discussed the effects of the expiration of the
statutory budget neutrality provision on rates and aggregate payments
under the capital prospective payment system. Under the budget
neutrality provision, we set the capital-prospective payment system
rates during FY 1992 through FY 1995 so that payments were projected to
equal 90 percent of Medicare payments that would have been made on a
reasonable cost basis for each fiscal year. As a result of the
provision's expiration in FY 1996, the capital-prospective payment
system rates and payments under the transition system increased
significantly. The FY 1996 Federal rate is 22.59 percent higher than
the FY 1995 Federal rate. We now estimate that aggregate capital
payments will increase 27.7 percent in FY 1996 relative to FY 1995, and
that payments will exceed capital costs by 9.6 percent in FY 1996.
Under current law and regulations, we estimate that aggregate payments
will further increase by 7.3 percent in FY 1997, for an increase of
37.0 percent over 2 years. We do not believe that such large increases
in capital payments are necessary or warranted.
During the FY 1996 rulemaking process, we solicited comments on
possible revisions to the capital prospective payment rates that would
have moderated these substantial increases in payments. At that time,
we noted that section 1886(g) of the Act gives the Secretary broad
discretion in the determination of the appropriate level of rates and
payments. However, we decided not to implement any reduction to the
capital rates at that time, in the expectation that Congress would be
considering revisions to rates and payments under the capital
prospective payment system within more comprehensive legislation
dealing with Medicare and the Federal budget.
In its March 1, 1996 Report to Congress, the Prospective Payment
Assessment Commission (ProPAC) observed that the base capital rate was
reduced during the first 4 years of the transition to full prospective
payment for capital to meet the statutory budget neutrality
requirement. In the light of the large increase in rates and payments
as a result of that provision's expiration in FY 1996, ProPAC
recommends (Recommendation 11) that the capital payment rates should be
set by developing an appropriate base payment rate and applying an
annual update. The Commission notes that there are several ways to
determine an appropriate base capital payment rate.
We agree with ProPAC that the large increase in rates and payments
caused by the expiration of the statutory budget neutrality provision
raises an issue concerning the proper level for future rates and
payments. We also agree that there are several possible approaches to
establishing an appropriate level for the rates. We considered a range
of options in developing this proposed rule. For example, we considered
proposing to freeze the inflation updates for the rates in FY 1997, on
the grounds that such an update was unnecessary and unwarranted in
light of the large increase in the rates for FY 1996. Alternatively, we
considered proposing actual reductions in the base rates. For example,
we considered proposing to implement the provision contained in the
Administration's budget plan. The Administration's FY 1997 budget
includes a provision to reduce the base Federal and hospital-specific
rates by 15.7 percent. Such a reduction would build the budget
neutrality adjustment for FY 1995 (0.8432, or -15.68 percent)
permanently into the base rates, effectively using the FY 1995 base
payment rate as the base for future years. The actual payment rates for
future years would then be determined by applying the analytical update
framework that we adopted in the final rule for FY 1996 (60 FR 45815-
45829). We also considered proposing to implement a part of the
Administration's proposal, that is, to reduce the standard Federal rate
by 7.38 percent and the hospital-specific rates by 9.48 percent. The
rationale for each of these options to reduce the base rate derives
from an analysis of current data compared to data on which the rate was
originally based.
Under Sec. 412.308, HCFA determined the standard Federal rate,
which is used to determine the Federal rate for each fiscal year, on
the basis of an estimate of the FY 1992 national average Medicare
capital cost per discharge. The FY 1992 national average Medicare
capital cost per discharge was estimated by updating the FY 1989
national average Medicare capital cost per discharge by the estimated
increase in Medicare inpatient capital cost per discharge. As we
discussed in the preamble to the August 30, 1991 capital prospective
payment system final rule (56 FR 43366-43384), HCFA used the July 1991
update of HCRIS data to estimate an FY 1989 national average Medicare
cost per case of $527.22.
[[Page 27480]]
HCFA then updated that amount to FY 1992 by using an actuarial
projection of a 31.3 percent increase in Medicare capital cost per
discharge from FY 1989 to FY 1992. The standard Federal rate was thus
based on an estimated FY 1992 national average Medicare capital cost
per discharge of $692.24 (before the application of a transfer
adjustment and a payment parameter adjustment).
Section 13501(a)(3) of Public Law 103-66 amended section
1886(g)(1)(A) of the Social Security Act to require that, for
discharges occurring after September 30, 1993, the unadjusted standard
Federal rate be reduced by 7.4 percent. As we discussed in the
September 1, 1993 final rule for FY 1994 (58 FR 46316ff.), the purpose
of that reduction was to reflect revised inflation estimates, as of May
1993, for the increases in Medicare capital costs per discharge during
FY 1989 through FY 1992. By that time, the estimate of increases in
Medicare inpatient capital costs per discharge from FY 1989 through FY
1992 had declined from 31.3 percent to 21.57 percent. The 7.4 percent
reduction to the Federal rate was calculated to account for these
revised estimates (1.2157/1.313=0.926, a 7.4 percent decrease). That
provision of Public Law 103-66 also required that, for cost reporting
periods beginning on or after October 1, 1993, the Secretary
redetermine which hospital payment methodology should be applied under
the capital prospective payment system transition rules to take into
account the 7.4 percent reduction to the Federal rate.
As a result of the reduction required by Public Law 103-66, the
standard Federal rate is now based on an estimated FY 1992 Medicare
inpatient capital cost per case of $641.01 ($692.24 x 0.926). At the
time of the Public Law 103-66 reduction to the Federal rate, actual
cost report data on the FY 1992 Medicare capital cost per discharge
were not yet available. The reduction was based on cost report data for
FY 1990 and FY 1991, and a revised projection of the rate of increase
in Medicare capital costs per discharge during FY 1992. We now have
extensive cost report data for FY 1992. The March 1996 update of HCRIS
data shows an audit-adjusted FY 1992 Medicare inpatient capital cost
per discharge of $593.72, or an additional 7.38 percent lower than the
estimate on which the Federal rate is currently based.
Under Sec. 412.328, HCFA determined the FY 1992 hospital-specific
rate by using a process similar to the process for determining the FY
1992 Federal rate. The intermediary determined each hospital's
allowable Medicare inpatient capital cost per discharge for the
hospital's latest cost reporting period ending on or before December
31, 1990. The intermediary then updated each hospital's FY 1990
allowable Medicare capital cost per discharge to FY 1992 based on the
estimated increase in Medicare inpatient capital cost per case. As with
the Federal rate updates, current data demonstrate that the estimates
used to update the hospital specific rates from FY 1990 to FY 1992 were
overstated. Specifically, the hospital-specific rates are 9.48 percent
higher than they would have been if the rates of increase had reflected
actual data. Thus, revising the Federal and the hospital-specific rates
only for the known overestimations in the actual costs on which rates
were based would call for reductions of 7.38 percent and 9.48 percent,
respectively.
The proposal in the Administration's budget to reduce the rates
15.7 percent reflects the preceding factors, as well as analysis of
capital cost increases before the implementation of the prospective
payment system for capital-related costs. That analysis suggests that
the Federal and hospital-specific rates may reflect levels of cost in
excess of what can be accounted for by the rate of inflation in capital
input prices, quality enhancing intensity increases, and real case mix
growth. Economic theory suggests that an industry with a guaranteed
return on capital (such as the hospital industry prior to prospective
payment for capital-related costs) would have a tendency to be overly
capitalized relative to more competitive industries. This is because
the incentive for firms in such an industry is to compete on the basis
of more capital-intensive production processes than firms in other
industries. As a result, capital costs per case, and therefore base
year prospective capital rates, may be higher than would have been
consistent with capital acquisition policy in more efficiency-oriented
markets.
To examine this issue, in our June 2, 1995 proposed rule (60 FR
29237) we analyzed the change in actual Medicare capital cost per case
for FY 1986 through FY 1992 in relation to the change in the capital
input price index (which accounts for change in the input prices for
capital-related costs), and the other adjustment factors that we were
then proposing to include in the framework. (The other adjustment
factors are the increase in real case mix and the increase in intensity
due to quality-enhancing technological change and within-DRG
complexity.) We found rates of increase in actual spending per case
that exceeded the rate of increase attributable to inflation in capital
input prices, quality-enhancing intensity increases, and real case-mix
growth. Our last analysis (60 FR 45826-45829) suggested that the FY
1992 capital costs used to set the Federal and hospital-specific
capital rates exceeded by approximately 28 percent the level that could
be accounted for by known factors.
We seriously considered proposing one of these options--reducing
the standard (base) Federal rate either 7.38 percent to address
overstated inflation estimates or 15.7 percent, as reflected in the
Administration's budget proposal--in this proposed rule. We believe
that either of these options is well justified on the basis of current
data and analysis. As ProPAC has observed, hospitals do not seem to
have been adversely affected by the level of the rates during the years
in which the statutory budget neutrality provision was in effect.
However, we still believe that Congress and the Administration may be
able to reach an agreement on budget issues, including Medicare
savings, in the near future. Therefore, as discussed in section III of
the Addendum to this proposed rule, at this time we are proposing to
update the capital rates in accordance with the capital update
framework, without implementing any of the reductions discussed above.
Our hope is that the legislative process will produce an appropriate
adjustment to the rate level in time for implementation in the final
rule. In the event that no such agreement is reached before the final
rule for FY 1997, we may implement one of the above-described options
at that time. We invite public comment on the merits of these options,
and on the advisability of implementing one or the other in the final
rule, in the absence of legislative action. We will reconsider all the
options in the light of public comments.
C. Possible Adjustment to Capital Prospective Payment System Minimum
Payment Levels
Section 412.348(b) of the regulations provides that, during the
capital prospective payment system transition period, any hospital may
receive an additional payment under an exceptions process if its total
inpatient capital-related payments under its payment methodology (i.e.,
fully prospective or hold-harmless) are less than a minimum percentage
of its allowable Medicare inpatient capital-related costs. The minimum
payment levels are established by class of hospitals under
Sec. 412.348(c). The minimum payment
[[Page 27481]]
levels for portions of cost reporting periods occurring in FY 1996 are:
Sole community hospitals (located in either an urban or
rural area), 90 percent;
Urban hospitals with at least 100 beds and a
disproportionate share patient percentage of at least 20.2 percent and
urban hospitals with at least 100 beds that qualify for
disproportionate share payments under Sec. 412.106(c)(2), 80 percent;
and,
All other hospitals, 70 percent.
Under Sec. 412.348(d), the amount of the exceptions payment is
determined by comparing the cumulative payments made to the hospital
under the capital prospective payment system to the cumulative minimum
payment levels applicable to the hospital for each cost reporting
period subject to that system. Any amount by which the hospital's
cumulative payments for previous cost reporting periods exceed its
cumulative minimum payment is deducted from the additional payment that
would otherwise be payable for a cost reporting period.
Section 412.348(h) further provides that total estimated exceptions
payments under the exceptions process may not exceed 10 percent of the
total estimated capital prospective payments (exclusive of hold-
harmless payments for old capital) for the same fiscal year. In the
final rule implementing the prospective payment system for capital-
related costs we stated that the minimum payment levels in subsequent
transition years would be revised, if necessary, to keep the projected
percentage of payments under the exceptions process at no more than 10
percent of capital prospective payments.
In section III of the Addendum to this proposed rule, we discuss
the factors and adjustments used to develop the FY 1997 Federal and
hospital-specific rates. In particular, we discuss the FY 1997
exceptions payment reduction factor. This factor adjusts the annual
payment rates for the estimated amount of additional payments for
exceptions in FY 1997. In this proposed rule, we estimate that
exceptions will equal 6.07 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. We will develop a new
estimate of the level of exceptions payments in FY 1997, and revise the
exceptions payment adjustment factor accordingly, on the basis of the
data that becomes available to us in time for developing the final rule
for FY 1997. While it is not necessary at this time to propose
reductions in the minimum payment levels, it is possible that it will
be necessary to implement adjustments to the minimum payment levels in
the final rule. Our current projections show that it will almost
certainly be necessary to adjust the minimum payment levels for FY
1998. We are therefore providing public notification that adjustments
to the minimum payment levels are possible in the final rule, and
almost certain for FY 1998.
When it does become necessary to adjust the minimum payment levels
in accordance with Sec. 412.348(h), our current intent is to adjust
each of the existing levels (i.e., 90 percent for sole community
hospitals, 80 percent for large urban DSH hospitals, and 70 percent for
all other hospitals) by 5 percentage point increments until estimated
exceptions payments are within the 10 percent limit. For example, we
would set minimum payment levels at 85 percent for sole community
hospitals, 75 percent for large urban DSH hospitals, and 65 percent for
all other hospitals, provided that aggregate exceptions payments at
those minimum payment levels were projected to be no more than 10
percent of total rate-based payments. If aggregate exceptions payments
at those minimum payment levels still exceeded 10 percent of total
rate-based payments, we would continue to reduce the minimum payment
levels by 5 percentage point increments each until the requirement of
Sec. 412.348(h) was satisfied. We are providing notification of our
current thinking on this issue in order to allow opportunity for public
comment on the appropriate method for adjusting the minimum payment
levels. We invite public comment on this matter, and will consider
those comments fully whenever it becomes necessary to adjust the
minimum payment levels in accordance with Sec. 412.348(h).
VII. Proposed Changes for Hospitals and Units Excluded From the
Prospective Payment Systems
Application of Ceiling in Calculating Payment for Hospital Inpatient
Operating Costs (Sec. 413.40 (d) and (g))
Section 1886(b)(1)(B) of the Act provides for an additional payment
to a hospital excluded from the prospective payment system when the
hospital's reasonable operating costs exceed its target amount. The
additional payment is based on the lesser of 50 percent of the amount
by which the operating costs exceed the target amount, or 10 percent of
the target amount. The Medicare statute further provides that this
comparison is made ``after any exceptions or adjustments are made to
such target amount for any cost reporting period.'' The regulations, at
42 CFR Sec. 413.40(d)(3), state that the total payment to the hospital
for inpatient operating costs (including the additional payment
described above) is based on the lesser of the following: the
``ceiling'' (target amount multiplied by the number of Medicare
discharges) plus 50 percent of the allowable net inpatient operating
costs in excess of the ceiling, or 110 percent of the ceiling. However,
the regulations do not explicitly include the additional statutory
requirement regarding the effect of exceptions or adjustments.
It is our understanding that there are questions about the
calculation of the additional payment under the regulations, which
require comparison of two amounts: the ``ceiling'' plus 50 percent of
the difference between allowable costs and the ceiling, and 110 percent
of the ``ceiling.'' Specifically, where a hospital has received an
adjustment to the target amount under Sec. 413.40(g), there has been
confusion as to whether the ``ceiling'' used for purposes of
calculating the additional payment under Sec. 413.40(d) is the
unadjusted ceiling (the amount determined without consideration of any
adjustments granted to the hospital) or the adjusted ceiling.
We believe that the amount of the additional payment should be
determined using the adjusted ceiling when hospitals receive
adjustments to the ceiling. That is, the calculation of the amounts
compared--50 percent of the allowable net inpatient operating costs in
excess of the ceiling, or 10 percent of the ceiling--should reflect the
adjusted target amount (and adjusted ceiling). To address any confusion
about these issues, we propose to revise Sec. 413.40(d)(3) to
specifically indicate that calculation of payments for hospital
inpatient operating costs under that provision reflects the adjusted
ceiling amount (the amount determined after an adjustment under
Sec. 413.40(g)). This would apply to all adjustments, including
adjustments based on a longer average length of stay in the hospital's
rate year as compared to the base year and adjustments for increased
routine services.
We note that an adjusted ceiling is not used to adjust permanently
the hospital's target amount or ceiling on the hospital's cost report.
Instead, it is used only for purposes of calculating payments for the
year the adjustment is granted. We also note that, depending on the
specifics of the data in a particular case, use of an adjusted ceiling
can result in either an increase or decrease in the additional payment
to a hospital relative to use of an unadjusted ceiling. If the
additional payment to a hospital is 50 percent of
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the allowable net inpatient operating costs in excess of the ceiling,
the additional payment would be lower using an adjusted ceiling (as
under proposed Sec. 413.40(d)(3)) than an unadjusted ceiling. This
would occur because an adjusted ceiling reduces the difference between
the hospital's costs and the ceiling. However, if the additional
payment to the hospital is 10 percent of the ceiling, the additional
payment would be higher using an adjusted ceiling than an unadjusted
ceiling.
VIII. ProPAC Recommendations
We have reviewed the March 1, 1996 report submitted by ProPAC to
Congress and have given its recommendations careful consideration in
conjunction with the proposals set forth in this document.
Recommendations 10 and 12, concerning the update factors for inpatient
operating costs, and the update factor for hospitals excluded from the
prospective payment system and distinct-part units, are discussed in
Appendix F to this proposed rule. Recommendation 11, on the setting of
capital payment rates, is discussed in section VI of this proposed
rule. Recommendations 17 and 18, concerning disproportionate share
hospitals, are discussed in section V of this proposed rule. The
remaining recommendations are discussed below.
A. Slowing the Rise in Medicare Spending (Recommendation 1)
Recommendation: The Commission supports the efforts of the Congress
and the President to reduce the growth in Medicare expenditures. Over
time, spending for services furnished to Medicare enrollees should
increase at rates comparable to those in a cost- and quality-conscious
private sector.
Response: We agree with ProPAC about the importance of slowing the
growth in Medicare spending. We support ProPAC's assertion that the
experience in the private sector with market forces that encourage cost
containment represents a useful factor in considering appropriate
growth in Medicare. We also agree with those factors upon which ProPAC
urges this comparison: spending growth on a per-person basis and
recognizing the health care needs of an aged and disabled Medicare
population. We caution, however, that while it may be appropriate to
compare growth service by service, aggregate comparisons would not be
meaningful due to differences in the mix of services.
Medicare and private health insurance provide a different array of
services. Medicare covers more long-term care services, such as home
health visits and skilled nursing facility (SNF) stays, than private
insurance. Although their share of total Medicare spending is small,
SNF and home health services are growing more quickly than other
services within Medicare, and therefore spending for these services has
been growing at a much faster rate than for other services. Data from
1992 and 1993 indicate that payments increased for SNF and home health
services by 40.6 percent and 35.2 percent, respectively, whereas the
growth in physician and hospital payments were only 4.5 percent and 8.3
percent, respectively. In order for Medicare and private health
insurance to grow, in aggregate, at the same rate, spending for
hospital and physician services would have to be growing more slowly in
Medicare than in private health insurance to offset differences in
long-term care growth. Due to these differences in mix of services,
meaningful comparisons between Medicare and the private sector can only
be made on a service-by-service basis.
B. The Failsafe Budget Mechanism (Recommendation 2)
Recommendation: Any failsafe budget mechanism should include a more
effective risk adjustment factor to ensure payment equity between the
Medicare capitation and traditional fee-for-service programs. In
addition, changes in inflation that differ substantially from
Congressional Budget Office (CBO) forecasts could require modifications
to the Medicare benefit budget over time. Revisions to the proposed
fee-for-service sector budget allocations could also be needed as
medical practices change.
Response: We believe that using a failsafe budget mechanism (that
is, an arbitrary cap on spending) to achieve targeted spending levels
would be bad public policy. A failsafe mechanism would fundamentally
change the nature of the Medicare program by breaking the link between
benefits and payments. To meet the cap, benefits might have to be
reduced, beneficiaries might have to pay more, and payments to
providers might have to be reduced, all of which would impede access. A
failsafe mechanism would encourage cost shifting to beneficiaries and
other payers in order to achieve the targeted goal in government
spending.
These arbitrary reductions in payments would make government an
unreliable business partner. As Medicare moves toward a more market-
oriented approach to setting payments, arbitrary reductions imposed by
the government, after providers have negotiated in good faith, would
sour relations and threaten the market pricing process.
The failsafe mechanism is a substitute for policy choices to
achieve the desired level of spending. This arbitrary Medicare budget
cap could potentially have adverse effects on the Medicare program.
We note that, while ProPAC recommends using a more effective risk
adjustment factor to ensure payment equity between Medicare capitated
and fee-for-service programs, no adequate case-mix measure currently
exists that could serve this purpose.
C. Expanding Medicare's Capitation Program (Recommendation 3)
Recommendation: The Commission supports reforming the Medicare
capitation program to control spending while expanding beneficiary
choice.
Response: HCFA agrees with this recommendation and has specifically
developed legislation to allow for Preferred Provider Organizations
(PPOs) and Provider Sponsored Organizations (PSOs) to contract with the
Medicare program. Furthermore, in October 1995, HCFA issued guidelines
that notified HMOS that they were permitted to develop Point of Service
(POS) Programs, which allow beneficiaries to go out of network for
services. HCFA is currently conducting the Choices Demonstration,
through which it is soliciting applications for the above types of
provider arrangements.
D. Setting and Updating the Capitation Rates (Recommendation 4)
Recommendation: Geographic variation in the capitation rates and
the volatility of the rates from year to year should be reduced. The
Secretary should develop and test alternative payment methods that
would allow the payment rates to reflect changes in local market
conditions.
Response: We agree that geographic variations in HCFA's payment
rates should be reduced. Some of the current legislative proposals
would reduce the degree of variation over time.
We have been looking at ways to reduce these variations. Several
demonstrations that should provide information needed to develop
alternative payment methods are either currently being run or in the
process of getting started. We have developed and are conducting
several research and demonstration projects to review additional risk
adjustors, which would modify current payment rates to reflect the
health status of the members of managed care organizations. Another
project would pay, from a separate pool of funds being shared by
several
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organizations in an area, for enrollees who have high Medicare costs.
Also, HCFA is in the process of starting another project that would
incorporate the payment principles associated with competitive bidding.
E. Improving Risk Adjustment Methods (Recommendation 5)
Recommendation: The risk adjustment methods used to set Medicare
capitation payments should better reflect variation in the likely use
of services. Even as research on the development of new methods
continues, the Secretary should implement interim improvements as soon
as possible.
Response: We plan to test health status risk adjusters, such as
Diagnostic Cost Groups or Ambulatory Care Groups, as part of the
Choices Demonstration. Furthermore, in this demonstration, we will test
reinsurance and partial capitation arrangements. We are also
considering demonstrations which use health status measures as part of
the Adjusted Community Rate Determination, as well as part of the
payment formula.
F. Medical Savings Accounts (MSAs) (Recommendation 6)
Recommendation: The Congress' high deductible/MSA option would
provide an additional choice for Medicare enrollees. However, ProPAC is
concerned that the current Medicare risk adjustment method is not
sufficient to protect the program from adverse selection and resulting
excess spending. The likelihood that rates would better reflect risk
would be enhanced if Medicare enrollees were required to remain in the
MSA option at least for several years.
Response: As ProPAC states, the Congressional Budget Office
estimated that the MSA option would cost the Medicare program $4.6
billion over 7 years, in part because of the current state-of-the-art
in risk adjustment methods (discussed in recommendation 5, above). The
CBO estimate of the cost of the MSA option is consistent with the cost
estimates of other reputable organizations. We fail to see the
rationale for including an option that provides no new benefits but is
expected to result in increased costs, particularly at a time when the
public and Congress are concerned about the long-term financial
viability of the Medicare program.
G. The Medicare Plus Fee-for-Service Option (Recommendation 7)
Recommendation: Enrollees choosing the fee-for-service option under
the proposed Medicare Plus program could be responsible for
substantially higher fees than what their plans would pay. The
Secretary should monitor the impact of this option on beneficiary
liability and on possible reductions in physician and other provider
participation in traditional Medicare.
Response: We agree with ProPAC that beneficiaries could be
responsible for substantially higher fees. We also agree that, as
suggested in this recommendation, allowing physicians and other
providers to elect to serve Medicare beneficiaries through private fee-
for-service plans that place no limits on extra-billing amounts may
well result in (1) increases in beneficiary liability and (2)
reductions in physicians and other providers participating in
traditional Medicare. Further, as the payment methods contained in
pending legislation described in H.R. 2491 are structured, the payment
increases for MedicarePlus plans, relative to those in fee-for-service
Medicare, mean that MedicarePlus plans would be able to pay physicians
and other providers more than fee-for-service Medicare. These higher
payments would create additional incentives for physicians and other
providers to cease participation in traditional Medicare. Finally,
while managed care plans potentially provide value added because their
organizational structure facilitates coordination of care, it is not
clear what, if any, value is added by creating a private fee-for-
service plan option, under which the private plans receive higher
payments relative to fee-for-service Medicare and physicians and
providers are permitted to charge unlimited extra-billing amounts.
H. Information for Beneficiary Health Plan Choices (Recommendation 8)
Recommendation: Medicare should make available to beneficiaries
information about the performance of plans and local providers. The
Secretary should identify the information beneficiaries need to make
appropriate choices and develop innovative ways to improve access to
it.
Response: Current HCFA initiatives to improve beneficiary
information about health insurance options, which are summarized below,
are consistent with ProPAC's recommendation.
Development of Prototype Materials and Strategies
We are currently engaged in two projects that will develop
prototype beneficiary information strategies related to health
insurance options.
The first project, which focuses mostly on managed care issues, is
examining through Medicare and Medicaid beneficiary focus groups, the
types of information and dissemination media that beneficiaries would
find most useful in selecting health insurance plans. Based on this
information, and case studies, the project will produce and test a
range of prototype beneficiary information materials, including
beneficiary health plan comparison booklets and charts, and
informational videos. Draft prototype materials (for Medicare, pre-
Medicare and Medicaid beneficiaries) are nearing completion and are
scheduled for beneficiary testing in Spring 1996.
The second project will design beneficiary information and
education materials and dissemination strategies to support the
Medicare Open Enrollment/Competitive Pricing demonstration. This
project will develop printed materials that explain the experimental
open enrollment process; printed general informational materials on
Medicare health insurance options; and booklets outlining the specific
Medicare fee-for-service and managed care options available to
beneficiaries in their area. A plan comparison chart template, which
would include information on specific benefits and premiums, will also
be developed, as will other information and educational approaches
(including educational seminars, public service announcements (PSAs),
informational videos, and a toll-free counseling phone line, all
sponsored by HCFA). In addition, a dissemination strategy for HCFA and
its partners in the demonstration sites will be developed (for example,
Insurance Counseling and Assistance (ICA) programs and beneficiary
advocacy groups).
Draft materials and strategies were tested on Medicare
beneficiaries in April 1996. Final products should be available for
adaptation to specific demonstration sites by Summer 1996.
Medicare Program Activities
We have currently outlined a strategy to produce and disseminate a
managed care plan comparison chart to Medicare beneficiaries, initially
through the HCFA Regional Offices and HCFA-sponsored ICA programs. We
will use comparison chart prototypes developed (under both of the
projects discussed above) as models for the comparison chart.
Prototypes will be available by Spring 1996. We plan to begin
dissemination of the basic comparability charts in 1996.
We may also choose to adapt some of the prototype materials for
application to the Medicare program, depending on feedback and
evaluations from
[[Page 27484]]
beneficiaries in the Open Enrollment Demonstration. These new materials
could ultimately supplement or replace current materials, such as the
Medicare Handbook. New prototype materials could also be provided and
adapted individually by the State ICA programs. We have contributed
recommendations during the development of these projects and will
continue to do so.
Many of the Regional Offices have developed area specific
informational materials related to Medicare managed care. The Regional
Offices typically use these materials to assist in their
responsibilities as the local HCFA contact for beneficiaries.
Related Major Initiatives
While current activities have centered on efforts to provide better
information on health insurance options (such as focusing on
comparisons of benefits, premiums, and locations), the next major steps
in improving information and educational strategies will likely be in
the area of quality or performance indicators.
The prototypes discussed above will include templates for eventual
dissemination of quality/performance indicators for health plans. In
addition, strategies for introducing the concept of indicators to
Medicare and Medicaid beneficiaries will be produced. One project,
short Medicare and Medicaid focused video tapes describing quality
indicators using a ``grocery shopping'' analogy, has already been
completed.
A final version of a set of Medicaid-specific National Committee on
Quality Assurance (NCQA) Health Plan Employer Data and Information Set
(HEDIS) quality indicators is nearly completed. We are currently
sponsoring the revision (with NCQA) of HEDIS version 3.0 to include
Medicare- specific measures. Once both Medicare- and Medicaid-specific
measures are available, HCFA will have available the basic tools
necessary to report comparative quality indicators to beneficiaries. A
specific dissemination strategy will then be determined.
We are currently in the developmental stages of a proposed plan-
specific Medicare beneficiary satisfaction survey. When completed, we
would have comparative satisfaction information on all Medicare managed
care plans, which could then be disseminated to beneficiaries as a
companion to plan benefit/premium comparison charts.
Based on these initiatives, HCFA should be well prepared to expand
and improve both the level and types of health insurance information
resources available to Medicare beneficiaries.
I. Health Plan Accountability (Recommendation 9)
Recommendation: Medicare must hold health plans accountable for the
appropriate use of Medicare funds. In addition, standards must be
developed and enforced to ensure that Medicare beneficiaries will
receive services of appropriate quality.
Response: We agree with these recommendations and have several
plans for implementing them. First, we are working with the National
Committee for Quality Assurance to develop HEDIS 3.0 for the Medicare
program. Second, we plan to conduct beneficiary satisfaction surveys
for a significant sample of beneficiaries from each health plan
participating in the Medicare HMO program. Third, we are working with
the Foundation of Accountability to develop condition-specific outcome
measures. Finally, we are working with Peer Review Organizations to
develop several condition-specific outcome measures that will be risk
adjusted.
J. Broadening Financial Support to Teaching Hospitals (Recommendation
13)
Recommendation: Explicit financial support for graduate medical
education activities should not be limited to the Medicare program.
Mechanisms to broaden financial support for teaching-related activities
in hospitals and other locations should be developed.
Response: The Commission is concerned that Medicare is the only
payer that provides explicit financial support for teaching activities.
Even though private payers provide implicit support through higher
prices for patient care services, funding is unrelated to the amount of
actual teaching activity.
While we would agree that all payers should contribute their fair
share toward physician training and particularly for the patient care
services that are provided in the course of this training, we wish to
emphasize that Medicare's support for graduate medical education is
limited only to Medicare's share of the total cost of graduate medical
education. That is, although we believe the current level of the
indirect medical education adjustment is higher than necessary to
compensate for the indirect costs associated with residents'
involvement in patient care, it is set at a level that at one time was
thought to equal those costs. Furthermore, because this adjustment is
made only for Medicare prospective payment system discharges, it is
inherently only associated with Medicare's share of the indirect costs
of graduate medical education. In addition, the direct graduate medical
education payment is calculated based on Medicare's inpatient
utilization rate, thereby ensuring that it, too, reflects only
Medicare's share of direct graduate medical education. In that vein, we
would support a mechanism to broaden support for physician training
that did not result in Medicare contributing more than its fair share,
relative to the Medicare utilization rate.
We note also that some Medicaid programs explicitly pay hospitals
for the indirect and direct costs of graduate medical education similar
to Medicare. In addition, some States (for example, New York, through
its Prospective Hospital Reimbursement Methodology) provide explicit
support for teaching hospitals through private payers. Nevertheless, we
join ProPAC in calling for more uniform support across all payers.
We would note that although the President's health care reform bill
attempted to involve private insurers in directly supporting medical
education, we do not currently have a proposal to broaden support for
teaching hospitals beyond that currently provided by Medicare. We have,
however, proposed to broaden financial support for teaching hospitals
by changing the way Medicare funds medical education through its
managed care programs. Currently, Medicare payments to HMOs are based
on the average cost of providing services to Medicare patients in the
fee for service part of Medicare. These payments to HMOs include
Medicare's costs for medical education. The President's FY 1997 budget
would revise Medicare's payments to HMOs so as not to include the
portion associated with medical education and paying these funds
directly to teaching hospitals and to managed care plans with teaching
programs. This change would benefit teaching hospitals, as well as more
appropriately target Medicare funds designated for medical education.
K. Medicare Payments for Graduate Medical Education Costs
(Recommendation 14)
Recommendation: ProPAC supports changes in Medicare teaching
payments that would encourage an appropriate distribution of residents
across specialties and discourage inappropriate growth in the total
number of residents.
Response: The Commission states that both the proposals of Congress
and the President's budgets would move Medicare direct graduate medical
education payments in the direction of
[[Page 27485]]
encouraging appropriate distribution of residents across specialties
and discourage inappropriate growth in the total number of residents.
The Administration is very concerned with the issue of Medicare
payments to hospitals for graduate medical education. Consistent with
numerous reports that the nation has an excess of specialty physicians,
and that the growth of managed care is increasing the demand for
primary care physicians relative to other specialties, the focus of the
President's graduate medical education proposal is to encourage greater
hospital participation in primary care residencies and less in
specialty residencies. In addition, a significant amount of training of
residents in primary care is more appropriately done in non-hospital
settings. Accordingly, the President's budget includes a cap on the
total number of residents and on the number of nonprimary care
residents for whom Medicare will make graduate medical education
payments. We would also encourage ambulatory training by including
residents who rotate to non-hospital settings in the hospital's FTE
count for IME purposes. We would further encourage ambulatory training
by providing direct medical education payments to facilities that are
not hospitals (for example, federally qualified health centers) for
residents, when the residents' salaries are not paid by hospitals.
The Administration has also proposed to create a Commission on
Medical Education and Workforce Priorities within HHS to develop and
recommend policies to address the preservation of academic health
centers' research and educational capacity and the supply of the future
health care workforce. This commission would also make recommendations
regarding the most effective allocation of training resources to ensure
that the numbers and competencies of health care professionals are
responsive to national needs.
L. Medicare Indirect Medical Education Payments (Recommendation 15)
Recommendation: The Medicare indirect medical education adjustment
should be reduced from its current 7.7 percent level to 7.0 percent.
Response: As we've said in response to similar ProPAC
recommendations in previous years, we agree with ProPAC that the
current level of payment for the indirect costs of medical education is
too high. The President's FY 1997 budget would reduce the adjustment
over 3 years to a final level of 6.0 percent effective for FY 1999. In
addition, residents working in nonhospital settings could be counted in
a hospital's resident count for indirect medical education purposes if
the hospital incurs all, or substantially all, of the costs for the
training program in that setting. Finally, the President's budget would
cap the number of residents that could be included in the count, with
an exception provided for primary care residents and those in the
specialties of obstetrics or gynecology.
The Commission also supported the provision in the President's FY
1996 budget that would apply the direct graduate medical education
resident count and weighting rules to the indirect medical education
count. However, ProPAC recommended proceeding with caution as
additional analysis would be needed to examine the effect of this
policy on individual teaching hospitals. We note that this provision is
not contained in the FY 1997 budget proposal. Therefore, residents
would continue to be counted for IME as long as they are enrolled in an
approved program.
M. Distributing Additional Teaching-Related Payments (Recommendation
16)
Recommendation: Funds that provide broader financial support for
graduate medical education should be distributed in a way that
corresponds to the additional costs incurred by teaching facilities.
Providers that treat enrollees in capitation plans should receive
teaching-related payments for those patients as well as for the other
patients they serve.
Response: This recommendation is related to Congress' proposal to
create new trust funds to provide broader support for educational
activities. Congress would create new trust funds that include accounts
for general direct medical education, general indirect medical
education, and a Medicare Plus Incentive Account financed by new
appropriations. This funding would be in addition to payments currently
being made by Medicare for direct and indirect medical education. The
Commission is concerned that the new funding would be distributed based
on previous Medicare payment levels even though general revenues will
fund the newly established trust funds. With regard to the Medicare
Plus Incentive Account, ProPAC is concerned that payments should give
Medicare's managed care participants an incentive to use teaching
hospitals and pay providers appropriately for serving patients in
capitation plans.
Like the Commission, we are concerned about appropriating general
revenues to finance medical education, particularly given our concern
that the indirect medical education adjustment already overcompensates
hospitals and Medicare already pays its share of costs of direct
medical education. The President's original proposal was to create an
all payer fund to finance graduate medical education. However, this
proposal was made in the context of overall health care reform. We
continue to remain concerned that medical education should be supported
to a greater extent by payers other than Medicare but have reservations
about financing of medical education with additional Federal money.
As we explained above in Recommendation 13, under the President's
FY 1997 budget, we would revise payments made through our managed care
programs to ensure that teaching programs are supported more
appropriately by existing Medicare resources designated for medical
education. Under the President's FY 1997 budget, payments for medical
education would be eliminated from HMO rates and redistributed to
teaching hospitals and managed care plans with teaching programs.
N. Discharges from Hospitals to Other Facilities (Recommendation 19)
Recommendation: Medicare payments should be modified to account for
the shift in services from acute to postacute settings. Broadening the
definition of transfer cases, however, is not an appropriate approach.
Response: In both the September 1, 1994 and September 1, 1995 final
rules, we expressed our concern that the current trend of declining
average lengths of stay as hospitals discharge Medicare patients into
alternative health care settings (other than acute care prospective
payment hospitals) in less time may result in a misalignment of
payments and costs under our existing payment systems (59 FR 45362; 60
FR 29221). In particular, we expressed concern over the potential for
hospitals paid under the prospective payment system to shift costs (for
which they are compensated through the DRG payments) to alternative
settings, which are in turn paid on a cost basis. Although we solicited
comments on possible solutions to this problem, we did not propose any
change in policy.
The President's FY 1997 budget includes a proposal to redefine
discharges from acute care hospitals to excluded hospitals and units
and skilled nursing facilities as transfers for payment purposes.
Currently, for cases transferred from one acute care hospital paid
under the prospective payment system to another like hospital, the
sending hospital is paid a per diem rate
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instead of the full DRG amount. For cases transferred to an excluded
hospital or unit or to a skilled nursing facility (as well as cases
discharged home or home with home health care), hospitals receive the
full DRG payment amount, regardless of the length of stay in the
hospital. Under the per diem transfer payment methodology, hospitals
receive a per diem amount (doubled for the first day of the stay) until
the full DRG amount is reached. Therefore, under the President's budget
proposal, hospitals transferring patients to excluded facilities or
skilled nursing facilities prior to the geometric mean length of stay
for the DRG, minus one day (to account for the double per diem on the
first day), would receive less than the full DRG amount for that case.
The basis for ProPAC's opposition to this proposal is that it ``* *
* thinks this policy would discourage the use of postacute providers.
Moreover, it could result in longer inpatient stays, which may not be
desirable or cost effective in the long run.'' We acknowledge that the
change in the definition of a transfer is not the ultimate solution to
this health care trend. In response to immediate concerns about
overpaying hospitals for the reduced services they are providing and
the rate of increase in expenditures for postacute care services,
however, we believe this is an appropriate interim measure while we
continue to explore long-term policy alternatives that will better
integrate our payment systems for care provided to Medicare
beneficiaries across the acute and postacute care settings.
O. Prospective Payment for PostAcute Care (Recommendation 20)
Recommendation: Prospective payment systems should be implemented
for all postacute services. The payment method for each service should
be consistent across delivery sites. The Secretary should explore
methods to control volume of postacute service use, such as bundling
services for a single payment.
Response: We agree that HCFA should develop prospective payment
systems for all postacute services, and we have made significant
progress in this area. As we discuss in our responses to
Recommendations 22 and 23, we have developed detailed implementation
plans for interim prospective payment systems for skilled nursing
facilities (SNFs) and home health agencies (HHAs) that do not require
patient classification systems. Execution of these plans will, of
course, require legislative action.
Beyond our interim plan, we have developed a strategy for
developing a full-fledged prospective payment system for SNFs. In the
absence of legislation, we have been pursuing data that could be used
to support a case-mix prospective payment system through our Multi-
State Case Mix Demonstration Project. This demonstration project, now
in its operational phase, is collecting data on patient case mix using
a modified version of the minimum data set, the assessment tool SNFs
use in developing patient care plans. Through the course of the
demonstration, we hope to gather data on the full range of SNF
resources needed for each resource utilization group. We are proceeding
to require by regulation that all facilities provide resident
assessment data. Consolidated billing of SNF services (that is,
requiring SNFs to bill for all services furnished to their patients)
and uniform coding of SNF services are also prerequisites for a SNF
prospective payment system. Consolidated billing and uniform coding are
needed to determine the appropriate payment for the ancillary services
component of SNF services and to provide useful data on the range of
services SNFs furnish.
We have also been working on a strategy to develop a full-fledged
prospective payment system for HHAs. We have funded a project to
develop outcome measures for home care that can be used for an outcome-
based quality improvement system. These measures will be based largely
on a core standard assessment data set that includes items measuring
sociodemographic, environmental, support system, health status,
functional status, and health service utilization characteristics of
patients. Many of these data items included in the core standard
assessment data set are not only essential for assessing patient
outcomes but are also critical for designing an adequate case-mix
system for payment purposes. To test and refine Medicare's approach to
outcome based quality improvement for home health care, HCFA is
currently sponsoring the Medicare Quality Assurance and Improvement
Demonstration, which uses this instrument. We plan to publish
regulations identifying the required data elements and addressing the
collection of information from the core standard assessment data set.
We also plan to sponsor additional research that would lead to an
appropriate case-mix adjuster that can be used in a national
prospective payment system.
In addition to the developmental work underway on SNF and HHA
prospective payment systems, we have begun work on the preliminary
steps necessary for the development of a prospective payment system for
hospital inpatient rehabilitation services. The biggest obstacle we
have faced in this effort is the lack of appropriate patient
classification systems for the types of patients treated by
rehabilitation hospitals. We have recently contracted with the Rand
Corporation to evaluate a rehabilitation coding system known as the
Functional Impairment Measure (FIM), which is a scoring system that
measures the degree of functional independence of rehabilitation
patients. These researchers will also evaluate the patient
classification system known as functional related groups (FRGs), which
are based on FIM, as a possible basis for a Medicare prospective
payment system for rehabilitation services. If the research confirms
functional status measures can be used to develop an appropriate
patient classification system, we will begin the additional work
necessary to put a prospective payment system into place. This would
require collecting patient assessment data from Medicare rehabilitation
hospitals and units and developing all the necessary components of the
new payment system. It will take at least 3 years to design and
implement such a system. To facilitate implementation, we are
considering initiating collection of patient assessment data in advance
of legislation establishing a prospective payment system. We will be
seeking public input on whether to proceed with a requirement for
patient assessment data in the absence of legislation and what data
elements should be included in a core data set that could be used not
only as the basis for a patient classification system but also to
assess outcomes.
We recognize that there are advantages to a coordinated approach in
developing prospective payment systems for postacute services and we
will be evaluating how to make them as consistent as possible. We also
recognize that the demand for implementation of prospective payment
systems for post-acute services is sufficiently immediate so that there
may not be time for the broad study, data collection, and research
needed to develop a ``unified'' system using similar resource grouping
principles. Most of the current legislative proposals, including the
Administration's proposals, would require implementation dates within
the next several years. It may not be feasible to develop a ``unified''
system within the time frames contemplated by the current legislative
proposals. Trade-offs may be required between continuation of the
interim payment systems versus
[[Page 27487]]
the full-blown prospective payment systems on one hand, and the
separate versus ``unified'' prospective payment systems on the other
hand.
P. Case-Mix Measures for PostAcute Services (Recommendation 21)
Recommendation: Reliable case-mix measurement is important in
prospective payment systems to account for resource use and to analyze
treatment patterns and costs across sites. The Secretary should
coordinate case-mix research across postacute care settings, using
consistent methods for measuring patient acuity and resource use.
Response: We are attempting to coordinate our work on case-mix
adjustment for home health care, long-term and SNF care, and
rehabilitative services. To develop a case-mix adjustment system for
SNF care, time studies were conducted in order to measure resource
utilization. Similarly, as noted above in response to Recommendation
20, we plan to fund research to identify a home health case-mix
adjuster.
In addition, in the case-mix work to date for both home health care
and SNF care, dependence in activities of daily living is the biggest
predictor of resource utilization. Some of the other predictors differ
across SNF care and home health care due to differences in the
treatment settings and the availability of information for a
classification system.
As also noted above in the preceding response, researchers at the
University of Pennsylvania have developed a classification system based
on FIMs called Function Related Groups (FIM-FRGs). This system appears
promising for use in a case-mix adjusted prospective payment system for
rehabilitation and long-term care facilities, and we are working with
the Rand Corporation on a research project to evaluate the suitability
of FIM-FRGs for this purpose.
We agree that a compatible cross-provider measure of resource use
would be the best multiplier in any universal postacute system. We also
believe that such measures do not now exist and to produce them would
require the program to incur significant costs and impose significant
data reporting and collection requirements on providers. We would
prefer to obtain explicit legislative direction before we incur these
costs and impose these burdens. Even so, we believe several years would
be required to gather the data and develop the case-mix measures. For
these reasons, we believe that interim prospective payment systems of
the types contained in the President's FY 1997 budget should be put in
place.
Q. Interim Fee-for-Service Payment Method for Skilled Nursing Facility
Services (Recommendation 22)
Recommendation: An interim payment method should be implemented to
control the growth in Medicare payments for SNF services until a
comprehensive prospective payment system is established. A system based
on historical data and facility-specific limits, however, may not allow
facilities to respond appropriately to changes in a dynamic
environment.
Response: We agree with ProPAC's recommendation that an interim
payment system should be developed until a permanent system is
established. Both the interim and permanent payment systems could
better promote the goals of quality care, maximum access to care, and
cost containment. A payment system that incorporates these goals is
essential as the nursing home industry evolves toward a more eclectic
mix of care levels and delivery models. In addition, the need exists
for a payment system that is simpler to administer for both providers
and HCFA. In order to maximize these goals, a permanent prospective
payment system for SNFs should include payment for all costs (that is,
routine operating, ancillary, and capital costs) and take into account
actual facility case mix. However, thecase-mix and ancillary cost data
necessary to accomplish this goal are not yet available.
In the interim, based on current data resources, a prospective
payment system could be implemented. It would apply solely to routine
costs (including routine capital costs) and utilize facility-specific
payment rates subject to cost limits. We are studying various cost
limit designs, such as regional limits versus national limits, to
account for geographical cost differences. In addition, methodologies
to ease the transition from the current payment system would be
incorporated into an interim prospective payment system.
While there is agreement that a need exists to implement an interim
prospective payment system for SNFs, the Commission believes that a
system based on historical data and facility-specific limits may not
allow facilities to respond appropriately to changes in a dynamic
environment. However, we believe that a facility-specific interim
prospective payment system would provide a number of advantages over
the current system, and could be constructed to accommodate changes in
a facility's case mix. The system would provide for greater cost
containment and administrative simplicity, through predetermined
pricing. In addition, the potential to earn a profit under the interim
system, by holding down costs, would provide an incentive for nursing
homes to participate in Medicare, or certify more beds if already
participating. This would provide greater access for beneficiaries.
This same incentive would produce greater efficiency in nursing home
operations and would support the provision of quality care. When
compared to a flat rate system, a facility-specific system would
maintain an appropriate distribution of payments, since the basis of
payments under the system is the nursing homes' own cost history. As a
nursing home case-mix classification system is finalized and tested,
and further analysis is completed on ancillary payment, these elements
would be incorporated into the payment system.
In addition, we are analyzing some features of an interim system
that would result in savings for the Medicare program. Specifically, in
developing providers' facility-specific payment rates for routine
services, the system would incorporate one set of cost limits based on
freestanding costs only. The current system provides for separate
(higher) limits for hospital-based facilities. Consequently, savings
would result from holding down payments to these hospital-based SNFs.
In addition, savings would result through the elimination of routine
cost limit exemptions granted to new providers of skilled nursing
services. The current system of cost limit exceptions for ``atypical
nursing services'' would be eliminated as well. Finally, the Medicare
Part B carrier fee schedules could be utilized for Part A SNF services
as a limit on the reasonable costs of certain ancillary services.
Currently, there are no limits or reasonable cost guidelines for many
of these services.
We support the ProPAC view that a per-episode payment system be
developed. We have noted above, however, that there are great obstacles
to developing both (1) prospective payment systems that are consistent
across provider types with respect to the method of measuring resource
use, and (2) classifications systems for episodes of postacute care
(either by provider type or in general) that account for a sufficient
degree of the variability among different types of patients. Thus, our
inclination would be to pursue our current plans for the prospective
payment systems with the thought that
[[Page 27488]]
further refinements could be made when data are available.
R. Interim Fee-for-Service Payment Method for Home Health Care
(Recommendation 23)
Recommendation: Until a fully prospective payment system for home
health care is developed, the Commission supports adopting episode-
based payment limits. In addition, beneficiary copayments, subject to
an annual limit, should be introduced.
Response: There is agreement between ProPAC and HCFA that an
interim cost control mechanism should be established prior to
implementing a prospective payment system for home health care. We
would like to highlight significant differences between the prospective
payment systems proposed by the Congress and the Administration.
The congressional proposal would limit payment to 120 days of
service with certain exceptions for up to 165 days of care. This
provision has the potential of serious financial impact on some
agencies, as well as reduced access to services for some patients with
the greatest needs. The proposal also assumes the availability of data
and systems to categorize and assign patients to one of the 18 ``case-
mix categories'' established in Phase II of HCFA's HHA prospective
payment system demonstration. Neither the data nor the systems are
currently in existence, and the implementation of such a system would
entail a major increase in the reporting burden on agencies. Were we
able to implement such a system, we estimate that the system would be
able to explain less than 10 percent of the variation in cost per
episode, at best.
The Administration's interim proposal entails no increased
reporting burden, as it uses data currently reported by agencies.
Although that budget proposal does not provide for per-episode
payments, its aggregate payment caps effectively create a per-episode
cap on costs. Given the uncertainty about the resource composition of
individual types of episodes, the use of an aggregate cap gives
agencies an incentive to provide services in a cost effective manner by
sharing savings with agencies whose costs are below their per
beneficiary limitation. We note that ProPAC was also concerned that the
interim proposal utilizes regional cost experience, which the
Commission feels may not be appropriate. The President's FY 1997 budget
includes a provision to use average national or regional cost
experience in constructing the per beneficiary limitation. We agree
with ProPAC that, should we find unjustified differences in regional
cost experience, we would support a move to national cost experience as
the basis for the per beneficiary limit.
It may be necessary to use regional rates to move individual HHAs
toward a national norm over time. This would avoid major displacements.
We are considering both regional and national blending.
We do not agree with the ProPAC recommendation that beneficiary
copayments be introduced. Our proposed interim system of limits should
adequately control the growth in service use. We do not agree with
shifting costs to beneficiaries, however limited, as a method of
controlling the growth in utilization.
As HCFA moves forward in designing a prospective payment system for
home health care, we will consider ProPAC's recommendations to look at
more uniformly defined units of services.
S. Update to the Composite Rate for Dialysis Services (Recommendation
24)
Recommendation: The Secretary should develop methods to control
total Medicare per capita expenditures for end stage renal disease
(ESRD) beneficiaries. In the meantime, the composite rate should be
updated by 2.7 percent for hospital-based dialysis facilities and by
2.0 percent for freestanding facilities for fiscal year 1997. The
Secretary should also develop reliable measures of patient severity and
outcomes to analyze the relationships among treatment processes,
patient outcomes, and costs. These factors should be considered in
evaluating the need for and the level of future payment updates.
Response: One of ProPAC's suggestions is that HCFA consider opening
enrollment for ESRD beneficiaries to participate in Medicare risk
programs. The reason for this recommendation is the rapid growth in
total Medicare spending for ESRD beneficiaries. A large part of this
increase is attributable to the expanding ESRD population, especially
older patients who require more services. These beneficiaries are using
more acute inpatient, skilled nursing and other dialysis-related
services than ever before. ProPAC suggests that to control these
expenditures, Medicare examine the possibility of adopting a capitation
payment system for ESRD services, since capitation rates have been
successful in controlling expenditure growth for other populations. At
a minimum, they are recommending that utilization review or other
managed care techniques be used to control the total volume of services
provided to ESRD beneficiaries across all sites of care.
Section 1876(d) of the Act currently prevents an individual with
ESRD from enrolling in an HMO or a competitive medical plan. However,
an individual who is enrolled in a prepaid health plan when he or she
is determined to have ESRD may continue enrollment in that plan. A
prepaid health plan may only disenroll a beneficiary as provided by
regulations at 417.460.
Congress addressed the issue of paying for ESRD services in a
capitation setting in legislation. Section 13567(b) of the Omnibus
Budget Reconciliation Act of 1993 (Public Law 103-66) (August 10, 1993)
amended section 2355 of Public Law 98-369 by requiring the Secretary to
include the integration of acute and chronic care management for
patients with ESRD through expanded community care case management
services in a social health maintenance organization (SHMO). Initial
legislation required the Secretary to grant demonstration waivers for
SHMOs that provide for the integration of health and social services at
a fixed annual prepaid capitation rate. In the January 26, 1996 Federal
Register, we published a notice informing interested parties of the
opportunity to apply for funds for a cooperative agreement to operate
an ESRD Managed Care Demonstration (61 FR 2516). Two of the
demonstration's purposes would be to test whether ESRD beneficiaries
can and should be given access to HMOs during open enrollment and
whether the statewide capitation rate can and should be adjusted. The
demonstration would adjust rates for treatment status (such as
dialysis, transplant, or a functioning graft), age groups and the cause
of renal failure (for example, diabetes). As the legislation requires,
rates would be based on 100 percent of the adjusted average per capita
costs (AAPCC); additional non-Medicare-covered benefits would be
offered by the provider to justify the additional 5 percent beyond the
95 percent of the AAPCC paid to Medicare risk-contracting HMOs on
behalf of ESRD enrollees. Based on the results of this demonstration,
we would make recommendations to Congress concerning the
appropriateness of paying for dialysis services in a capitation
setting.
To improve the quality of care ESRD patients are receiving, we are
in the process of developing proposed rules for ESRD conditions for
coverage. The essence of the regulation is patient-centered and
outcome-oriented. The proposed conditions for coverage will focus on
facilities achieving an optimal
[[Page 27489]]
level of health and well-being for all dialysis patients. The proposed
rules will be published in Spring 1996 with expected implementation in
late fiscal year 1997.
While we share ProPAC's concern that payment rates be sufficient to
assure quality care for ESRD patients, we do not believe there is
sufficient evidence at this point to conclude that more money is needed
to provide appropriate care. Currently, the University of Michigan, as
part of a National Institute of Health grant, is examining the
relationship between facilities' costs and the level of KT/V. Also the
National Institute of Diabetes and Digestive and Kidney Diseases is
sponsoring a study on the impact of increasing dialysis as measured by
KT/V and the use of high-flux-dialysis on ESRD patients. The results of
these studies should help us analyze the relationship between patient
outcomes and costs, and thus provide us with a basis for recommending
an appropriate payment rate increase.
While we acknowledge that an increase in the composite rate may be
appropriate in the next few years, we believe that any rate increase
should be linked to implementation of the revised conditions for
coverage. Moreover, any ESRD rate increase must be considered within
the context of Medicare budgetary concerns and should have a direct
link to improved patient outcomes. We will continue to monitor ESRD
facility costs, and, if appropriate, we may recommend an update to the
ESRD composite rate for FY 1998.
We note that ProPAC's recommendation provides for an across-the-
board rate increase for all renal facilities. However, data show that
high volume independent facilities (over 6,000 treatments per year)
account for about 85 percent of independent dialysis treatments. These
high volume facilities report margins between Medicare payments and
costs that are higher than average. Therefore, in proposing a future
rate increase, we would want to examine the need to adjust payment
increases for volume. In addition, we believe that any update to the
composite rate should include an update to the wage index currently
used to adjust the labor portion of the rate. We are currently using an
outdated wage index which is a blend of 1980 Bureau of Labor Statistics
(BLS) and 1984 prospective payment system wage data and does not
reflect the MSA revisions resulting from the 1990 census.
The Commission's final recommendation is that the Secretary closely
monitor treatment patterns and patient outcomes to ensure that
facilities use the payment increase to improve quality of care. The
proposed ESRD conditions for coverage should address this issue. We
expect the proposed rule to be published in the Federal Register before
Summer 1996. Between the publication of the proposed and final rules,
HCFA is planning to meet with the renal community to develop complete
clinical data sets to monitor patient outcomes and medical conditions.
These data will then be used to evaluate the quality of dialysis
services furnished by individual facilities. Of course, this is a long-
term project. In the short term, we are exploring the possibility of
collecting limited patient outcome data such as KT/V and URR.
T. Prospective Payment for Hospital Outpatient Services (Recommendation
25)
Recommendation: A comprehensive prospective payment system should
be developed for hospital outpatient services. Such a system should
include a strategy for controlling the volume of ambulatory services.
Response: We agree with the need to implement a comprehensive
prospective payment system for outpatient services. While we await
legislative authority, we continue to develop and refine the Medicare-
specific factors of the Ambulatory Patient Group (APG) system that we
recommend using. We plan to analyze the payments that would be made
across sites, for example in Ambulatory Surgical Centers (ASCs) or
physician radiology practices, to ensure that we have not created
unwarranted incentives to perform procedures in a given setting for
financial reasons.
We are concerned as well about the potential for increases in the
volume of services provided, both in outpatient departments and in
other settings. We are examining approaches to volume measurement and
control, including the level of packaging for ancillary services and
monitoring of patterns of care. For example, we could track whether
Medicare beneficiaries received more clinic visits per patient under
APGs than they did under cost-based reimbursement. If so, we could take
corrective action either systemically or on a hospital-specific basis.
This issue clearly requires study. We welcome suggestions in this area.
U. Beneficiary Liability for Hospital Outpatient Services
(Recommendation 26)
Recommendation: The growing financial burden for Medicare enrollees
who receive services in hospital outpatient departments should be
alleviated immediately. Beneficiary coinsurance for these services
should be limited to 20 percent of the Medicare-allowed payment, as it
is in other settings. For services not paid on a prospective basis, the
Secretary should establish a new method for determining beneficiary
copayments based on estimated allowed payments since they cannot be
calculated precisely when services are delivered.
Response: We agree that the issue of beneficiary coinsurance should
be addressed. In the context of the monies available to the Medicare
program, we doubt that Congress would authorize that Medicare
immediately assume the full cost of paying 80 percent of the cost of
outpatient services. Among the approaches that could be used are: (1)
Applying the savings achieved by eliminating the formula-driven
overpayment to offset the beneficiaries' responsibility; (2) requiring
copayments in other areas of the program, such as for home health
services or laboratory services; and/or (3) moving gradually to reduce
the ratio of copayments to total payments. One issue that must be
considered at the same time is the rise in the Part B premium that
would accompany any significant increase in program payments. This
would have the effect of distributing costs over the entire range of
beneficiaries, rather than having it focused only on those patients who
actually use outpatient services, as it is now. We are eager to have
this issue addressed and resolved, but know that it must be examined in
light of broader budget decisions.
IX. Other Required Information
A. Paperwork Reduction Act
The Paperwork Reduction Act of 1995 provides for notice and comment
when a collection of information requirement is submitted to the Office
of Management and Budget (OMB) for review and approval. In order to
fairly evaluate whether an information collection should be approved by
OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995
requires that we solicit comment on the following issues:
Whether the information collection is necessary and useful
to carry out the proper functions of the agency;
The accuracy of the agency's estimate of the information
collection burden;
The quality, utility, and clarity of the information to be
collected; and
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
[[Page 27490]]
Therefore, we are soliciting public comment on each of these issues for
the information collection requirement discussed below.
The only information collection or paperwork burden item contained
in this proposed rule involves the requirement under Sec. 489.27 that a
hospital furnish each Medicare beneficiary with a notice of discharge
rights supplied by HCFA, that is, `An Important Message from Medicare.'
As discussed in section V.F of this preamble, we are revising the
current requirement that a hospital must distribute the `Important
Message' to each Medicare beneficiary at or about the time of
admission. In order to permit hospitals more flexibility, but still
ensure that benficiaries are aware of their discharge rights, we are
proposing to revise Sec. 489.27 to specify that a hospital must provide
the notice of discharge rights `during the course of the hospital
stay.' We estimate that the paperwork burden associated with the
requirement that hospital personnel distribute the `Important Message'
to each Medicare beneficiary is approximately 1 minute per admission.
Based on our most recent available data (1995 Data Compendium, HCFA
Pub. No. 03364), there are roughly 11 million Medicare beneficiaries
admitted to hospitals each year, resulting in an annual burden of
approximately 183,000 hours.
This paperwork burden is not effective until it has been approved
by OMB. A notice will be published in the Federal Register when
approval is obtained. Organizations and individuals desiring to comment
on this paperwork burden requirement should submit comments by July 30,
1996 to the Office of Management and Budget, Human Resources and
Housing Branch, Room 10235, New Executive Office Building, Washington,
D.C., 20503, Attention: Allison Herron Eydt, HCFA Desk Officer.
B. Requests for Data from the Public
In order to respond promptly to public requests for data related to
the prospective payment system, we have set up a process under which
commenters can gain access to the raw data on an expedited basis.
Generally, the data are available in computer tape format or
cartridges; however, some files are available on diskette, and on the
internet at HTTP://WWW.HCFA.GOV/STATS/PUBFILES.HTML. Data files are
listed below with the cost of each. Anyone wishing to purchase data
tapes, cartridges, or diskettes should submit a written request along
with a company check or money order (payable to HCFA-PUF) to cover the
cost, to the following address: Health Care Financing Administration,
Public Use Files, Accounting Division, P.O. Box 7520, Baltimore,
Maryland 21207-0520, (410) 786-3691. Files on the internet may be
downloaded without charge.
1. Expanded Modified MEDPAR-Hospital (National)
The Medicare Provider Analysis and Review (MEDPAR) file contains
records for 100 percent of Medicare beneficiaries using hospital
inpatient services in the United States. (The file is a Federal fiscal
year file which means discharges occurring October 1 through September
30.)The records are stripped of most data elements that will permit
identification of beneficiaries. The hospital is identified by the 6-
position Medicare billing number. The file is available to persons
qualifying under the terms of the Notice of Proposed New Routine Uses
for an Existing System of Records published in the Federal Register on
December 24, 1984 (49 FR 49941), and amended by the July 2, 1985 notice
(50 FR 27361). The national file consists of approximately 11 million
records. Under the requirements of these notices, a data release
agreement must be signed by the purchaser before release of these data.
For all files requiring a signed data release agreement, please write
or call to obtain a blank agreement form before placing an order. Two
versions of this file are created each year. They support the
following:
Notice of Proposed Rulemaking (NPRM) published in the
Federal Register, usually available by the end of May. This file is
derived from the MedPAR file with a cutoff of 3 months after the end of
the fiscal year (December file).
Final Rule published in the Federal Register, usually
available by the first week of September. This file is derived from the
MedPAR file with a cutoff of 9 months after the end of the fiscal year
(June file).
Media: Tape/Cartridge
File Cost: $3,415.00 per fiscal year
Periods Available: FY 1988 through FY 1995
2. Expanded Modified MedPAR-Hospital (State)
The State MedPAR file contains records for 100 percent of Medicare
beneficiaries using hospital inpatient services in a particular State.
The records are stripped of most data elements that will permit
identification of beneficiaries. The hospital is identified by the 6-
position Medicare billing number. The file is available to persons
qualifying under the terms of the Notice of Proposed New Routine Uses
for an Existing System of Records published in the December 24, 1984
Federal Register notice, and amended by the July 2, 1985 notice. This
file is a subset of the Expanded Modified MedPAR-Hospital (National) as
described above. Under the requirements of these notices, a data
release must be signed by the purchaser before release of these data.
Two versions of this file are created each year. They support the
following:
NPRM published in the Federal Register, usually available
by the end of May. This file is derived from the MedPAR file with a
cutoff of 3 months after the end of the fiscal year (December file).
Final Rule published in the Federal Register, usually
available by the first week of September. This file is derived from the
MedPAR file with a cutoff of 9 months after the end of the fiscal year
(June file).
Media: Tape/Cartridge
File Cost: $1,050.00 per State per year
Periods Available: FY 1988 through FY 1995
3. HCFA Hospital Wage Index Data File
This file is composed of four separate diskettes. Included are: (1)
The hospital hours and salaries for FY 1993 used to create the proposed
FY 1997 prospective payment system wage indexes; (2) a history of all
wage indexes used since October 1, 1983; (3) a list of State and county
codes used by SSA and FIPS (Federal Information Processing Standards),
county name, and Metropolitan Statistical Area (MSA); and (4) a file of
hospitals that were reclassified for the purpose of the FY 1997 wage
index. Two versions of these files are created each year. They support
the following:
NPRM published in the Federal Register, usually by the end
of May.
Final Rule published in the Federal Register, usually by
the first week of September.
Media: Diskette/Internet
File Cost: $500.00
Periods Available: FY 1997 PPS Update
We note that the files also are available individually as indicated
below.
(1) HCFA Hospital Wage Index Survey Only (usually available by the
end of March for the NPRM and the middle of August for the final rule.)
(2) Urban and Rural Wage Indices Only
(3) PPS SSA/FIPS MSA State and County Crosswalk Only (usually
available by the end of March)
[[Page 27491]]
(4) Reclassified Hospitals by Provider Only
Media: Diskette/Internet
File cost: $145.00 per file
4. PPS-IV to PPS-XII Minimum Data Sets
The Minimum Data Set contains cost, statistical, financial, and
other information from the Medicare hospital cost report. The data set
includes only the most current cost report (as submitted, final settled
or reopened) submitted for a Medicare participating hospital by the
Medicare Fiscal Intermediary to HCFA. This data set is updated at the
end of each calendar quarter and is available on the last day of the
following month.
Media: Tape/Cartridge
------------------------------------------------------------------------
Periods
beginning on and before
or after
------------------------------------------------------------------------
PPS IV.................................. 10/01/86 10/01/87
PPS V................................... 10/01/87 10/01/88
PPS VI.................................. 10/01/88 10/01/89
PPS VII................................. 10/01/89 10/01/90
PPS VIII................................ 10/01/90 10/01/91
PPS IX.................................. 10/01/91 10/01/92
PPS X................................... 10/01/92 10/01/93
PPS XI.................................. 10/01/93 10/01/94
PPS XII................................. 10/01/94 10/01/95
------------------------------------------------------------------------
(Note: The PPS XII Minimum Data Set covering 1995 will not be available
until July 31, 1996.)
File Cost: $715.00 per year
5. PPS-IX to PPS-XII Capital Data Set
The Capital Data Set contains selected data for capital-related
costs, interest expense and related information and complete balance
sheet data from the Medicare hospital cost report. The data set
includes only the most current cost report (as submitted, final settled
or reopened) submitted for a Medicare certified hospital by the
Medicare fiscal intermediary to HCFA. This data set is updated at the
end of each calendar quarter and is available on the last day of the
following month.
Media: Tape/Cartridge
------------------------------------------------------------------------
Periods
beginning on and before
or after
------------------------------------------------------------------------
PPS IX.................................. 10/01/91 10/01/92
PPS X................................... 10/01/92 10/01/93
PPS XI.................................. 10/01/93 10/01/94
PPS XII................................. 10/01/94 10/01/95
------------------------------------------------------------------------
(Note: The PPS XII Capital Data Set covering 1994 will not be available
until July 31, 1996.)
File Cost: $715.00 per year
6. Provider-Specific File
This file is a component of the PRICER program used in the fiscal
intermediary's system to compute DRG payments for individual bills. The
file contains records for all prospective payment system eligible
hospitals, including hospitals in waiver States, and data elements used
in the prospective payment system recalibration processes and related
activities. Beginning with December 1988, the individual records were
enlarged to include pass-through per diems and other elements.
Media: Tape/Cartridge
File Cost: $500.00 per file
Periods Available: FY 1987 through FY 1996 (December updates)
Media: Diskette/Internet
File Cost: $265.00
Periods Available: FY 1996 PPS Update
7. HCFA Medicare Case-Mix Index File
This file contains the Medicare case-mix index by provider number
as published in each year's update of the Medicare hospital inpatient
prospective payment system. The case-mix index is a measure of the
costliness of cases treated by a hospital relative to the cost of the
national average of all Medicare hospital cases, using DRG weights as a
measure of relative costliness of cases. Two versions of this file are
created each year. They support the following:
NPRM published in the Federal Register, usually by the end
of May.
Final rule published in the Federal Register, usually by
the first week of September.
Media: Diskette/Internet
Price: $145.00 per year
Periods Available: FY 1985 through FY 1995 (Internet--FY 1995)
8. Table 5 DRG File
This file contains a listing of DRGs, DRG narrative description,
relative weight, geometric mean, length of stay, and day outlier trim
points as published in the Federal Register. The hardcopy image has
been copied to diskette. There are two versions of this file as
published in the Federal Register:
a. NPRM, usually published by the end of May.
b. Final rule, usually published by the first week of September.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1997 PPS Update
9. PPS Payment Impact File
This file contains data used to estimate payments under Medicare's
hospital inpatient prospective payment systems for operating and
capital-related costs. The data are taken from various sources,
including the Provider-Specific File, Minimum Data Sets, and prior
impact files. The data set is abstracted from an internal file used for
the impact analysis of the changes to the prospective payment systems
published in the Federal Register. This file is available for release 1
month after the proposed and final rules are published in the Federal
Register.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1997 PPS Update
10. AOR/BOR Tables
This file contains data used to develop the DRG relative weights.
It contains mean, maximum, minimum, standard deviation and coefficient
of variation statistics by DRG for length of stay and standardized
charges. The BOR tables are ``Before Outliers Removed'' and the AOR is
``After Outliers Removed.'' (Outliers refers to statistical outliers,
not payment outliers.) Two versions of this file are created each year.
They support the following:
NPRM published in the Federal Register, usually by the end
of May.
Final rule published in the Federal Register, usually by
the first week of September.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1997 PPS Update
11. HCFA FY 1992 Capital-Related Tax File
This file contains data used to develop a special property tax
adjustment to the capital prospective payment system for capital-
related costs. The data set includes a preliminary hospital-specific
add-on amount for all PPS hospitals. The data set also contains the
information used to propose an adjustment to the Federal rate so that
the tax add-on is budget neutral. The proposed property tax adjustment
provides special treatment to qualified hospitals who pay capital-
related property taxes. The add-on was 10. determined using base year
tax costs per discharge attributable to Medicare. The data are taken
from the FY 1992 Medicare hospital cost report and a special request
for validation by the fiscal intermediaries.
Media: Diskette
File cost: $145.00
Period available: FY 1992
For further information concerning these data tapes, contact Mary
R. White at (410) 786-0168.
Commenters interested in obtaining or discussing any other data
used in constructing this rule should contact Stephen Phillips at (410)
786-4548.
[[Page 27492]]
C. Public Comments
Because of the large number of items of correspondence we normally
receive on a proposed rule, we are not able to acknowledge or respond
to them individually. However, in preparing the final rule, we will
consider all comments concerning the provisions of this proposed rule
that we receive by the date and time specified in the ``Dates'' section
of this preamble and respond to those comments in the preamble to that
rule. We emphasize that, given the statutory requirement under section
1886(e)(5) of the Act that our final rule for FY 1997 be published by
September 1, 1996, we will consider only those comments that deal
specifically with the matters discussed in this proposed rule.
List of Subjects
42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 489
Health facilities, Medicare.
42 CFR chapter IV would be amended as set forth below:
A. Part 412 would be amended as follows:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart D--Basic Methodology for Determining Prospective Payment
Federal Rates for Inpatient Operating Costs
2. In Sec. 412.63(s)(1), a new sentence is added at the end to read
as follows:
Sec. 412.63 Federal rates for inpatient operating costs for fiscal
years after Federal fiscal year 1984.
* * * * *
(s) * * *
(1) * * * The wage index is updated annually.
* * * * *
Subpart L--The Medicare Geographic Classification Review Board
3. In 412.246, paragraph (b) is revised to read as follows:
Sec. 412.246 MGCRB members.
* * * * *
(b) Term of office. The term of office for an MGCRB member may not
exceed 3 years. A member may serve more than one term. The Secretary
may terminate a member's tenure prior to its full term.
Subpart M--Prospective Payment System for Inpatient Hospital
Capital Costs
4. In Sec. 412.302, a new paragraph (d)(4) is added to read as
follows:
Sec. 412.302 Introduction to capital costs.
* * * * *
(d) * * *
(4) Hospitals may elect the simplified cost allocation methodology
under the terms and conditions provided in the instructions for HCFA
Form 2552.
B. Part 413 would be amended as follows:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED
PAYMENT RATES FOR SKILLED NURSING FACILITIES
1. The authority citation for part 413 continues to read as
follows:
Authority: Secs. 1102, 1861(v)(1)(A), and 1871 of the Social
Security Act (42 U.S.C. 1302, 1395x(v)(1)(A), and 1395hh).
Subpart C--Limits on Cost Reimbursement
2. In Sec. 413.40, paragraph (d)(3) is revised to read as follows:
Sec. 413.40 Ceiling on the rate of increase in hospital inpatient
costs.
* * * * *
(d) * * *
(3) Net inpatient operating costs are greater than the ceiling. For
cost reporting periods beginning on or after October 1, 1991, if a
hospital's allowable net inpatient operating costs exceed the
hospital's ceiling (or the adjusted ceiling, if applicable), payment
will be based on the lower of the--
(i) Ceiling (or the adjusted ceiling, if applicable) plus 50
percent of the allowable net inpatient operating costs in excess of the
ceiling (or the adjusted ceiling, if applicable); or
(ii) One hundred-ten percent of the ceiling (or the adjusted
ceiling, if applicable).
* * * * *
Subpart F--Specific Categories of Costs
3. In Sec. 413.86, a new sentence is added at the end of paragraph
(g)(1) introductory text to read as follows:
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(g) * * *
(1) * * * For combined residency programs, an inital residency
period is defined as the time required for individual certification in
the longer of the two programs.
* * * * *
C. Part 489 would be amended as follows:
PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL
1. The authority citation for part 489 continues to read as
follows:
Authority: Secs. 1102, and 1871 of the Social Security Act (42
U.S.C. 1302, and 1395hh).
Subpart B--Essentials of Provider Agreements
2. Section 489.27 is revised to read as follows:
Sec. 489.27 Beneficiary notice of discharge rights.
A hospital that participates in the Medicare program must furnish
each Medicare beneficiary, or an individual acting on his or her
behalf, the notice of discharge rights HCFA supplies to the hospital to
implement section 1886(a)(1)(M) of the Act. The hospital must provide
timely notice during the course of the hospital stay. For purposes of
this paragraph, the course of the hospital stay may begin with the
provision of a package of information regarding scheduled preadmission
testing and registration for a planned hospital admission. The hospital
must be able to demonstrate compliance with this requirement.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
[[Page 27493]]
Dated: May 13, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: May 24, 1996.
Donna E. Shalala,
Secretary.
[Editorial Note: The following addendum and appendixes will not
appear in the Code of Federal Regulations.]
Addendum--Proposed Schedule of Standardized Amounts Effective With
Discharges on or After October 1, 1996 and Update Factors and Rate-
of-Increase Percentages Effective With Cost Reporting Periods
Beginning on or After October 1, 1996
I. Summary and Background
In this addendum, we are setting forth the proposed amounts and
factors for determining prospective payment rates for Medicare
inpatient operating costs and Medicare inpatient capital-related costs.
We are also setting forth proposed rate-of-increase percentages for
updating the target amounts for hospitals and hospital units excluded
from the prospective payment system.
For discharges occurring on or after October 1, 1996, except for
sole community hospitals and hospitals located in Puerto Rico, each
hospital's payment per discharge under the prospective payment system
will be based on 100 percent of the Federal national rate.
Sole community hospitals are paid based on whichever of the
following rates yields the greatest aggregate payment: the Federal
national rate, the updated hospital-specific rate based on FY 1982 cost
per discharge, or the updated hospital-specific rate based on FY 1987
cost per discharge. For hospitals in Puerto Rico, the payment per
discharge is based on the sum of 75 percent of a Puerto Rico rate and
25 percent of a national rate (section 1886(d)(9)(A) of the Act).
As discussed below in section II, we are proposing to make changes
in the determination of the prospective payment rates for Medicare
inpatient operating costs. The changes, to be applied prospectively,
would affect the calculation of the Federal rates. In section III, we
discuss our proposed changes for determining the prospective payment
rates for Medicare inpatient capital-related costs. Section IV sets
forth our proposed changes for determining the rate-of-increase limits
for hospitals excluded from the prospective payment system. The tables
to which we refer in the preamble to the proposed rule are presented at
the end of this addendum in section V.
II. Proposed Changes to Prospective Payment rates For Inpatient
Operating Costs for FY 1997
The basic methodology for determining prospective payment rates for
inpatient operating costs is set forth at Sec. 412.63 for hospitals
located outside of Puerto Rico. The basic methodology for determining
the prospective payment rates for inpatient operating costs for
hospitals located in Puerto Rico is set forth at Secs. 412.210 and
412.212. Below, we discuss the manner in which we are changing some of
the factors used for determining the prospective payment rates. The
Federal and Puerto Rico rate changes, once issued as final, will be
effective with discharges occurring on or after October 1, 1996. As
required by section 1886(d)(4)(C) of the Act, we must also adjust the
DRG classifications and weighting factors for discharges in FY 1997.
In summary, the proposed standardized amounts set forth in Tables
1a and 1c of section V of this addendum reflect--
Updates of 2.2 percent for all areas (that is, the market
basket percentage increase of 2.7 percent minus 0.5 percentage points);
An adjustment to ensure budget neutrality as provided for
in sections 1886 (d)(4)(C)(iii) and (d)(3)(E) of the Act by applying
new budget neutrality adjustment factors to the large urban and other
standardized amounts;
An adjustment to ensure budget neutrality as provided for
in section 1886(d)(8)(D) of the Act by removing the FY 1996 budget
neutrality factor and applying a revised factor; and
An adjustment to apply the revised outlier offset by
removing the FY 1996 outlier offsets and applying a new offset.
A. Calculation of Adjusted Standardized Amounts
1. Standardization of Base-Year Costs or Target Amounts
Section 1886(d)(2)(A) of the Act required the establishment of
base-year cost data containing allowable operating costs per discharge
of inpatient hospital services for each hospital. The preamble to the
September 1, 1983 interim final rule (48 FR 39763) contains a detailed
explanation of how base-year cost data were established in the initial
development of standardized amounts for the prospective payment system
and how they are used in computing the Federal rates.
Section 1886(d)(9)(B)(i) of the Act required that Medicare target
amounts be determined for each hospital located in Puerto Rico for its
cost reporting period beginning in FY 1987. The September 1, 1987 final
rule contains a detailed explanation of how the target amounts were
determined and how they are used in computing the Puerto Rico rates (52
FR 33043, 33066).
The standardized amounts are based on per discharge averages of
adjusted hospital costs from a base period or, for Puerto Rico,
adjusted target amounts from a base period, updated and otherwise
adjusted in accordance with the provisions of section 1886(d) of the
Act. Sections 1886 (d)(2)(C) and (d)(9)(B)(ii) of the Act required that
the updated base-year per discharge costs and, for Puerto Rico, the
updated target amounts, respectively, be standardized in order to
remove from the cost data the effects of certain sources of variation
in cost among hospitals. These include case mix, differences in area
wage levels, cost of living adjustments for Alaska and Hawaii, indirect
medical education costs, and payments to hospitals serving a
disproportionate share of low-income patients.
Since the standardized amounts have already been adjusted for
differences in case mix, wages, cost-of-living, indirect medical
education costs, and payments to hospitals serving a disproportionate
share of low-income patients, no additional adjustments for these
factors for FY 1997 were made. That is, the standardization adjustments
reflected in the FY 1997 standardized amounts are the same as those
reflected in the FY 1996 standardized amounts.
Under sections 1886 (d)(2)(H) and (d)(3)(E) of the Act, in making
payments under the prospective payment system, the Secretary estimates
from time to time the proportion of costs that are wages and wage-
related costs. Since October 1, 1990, when the market basket was last
rebased, we have considered 71.4 percent of costs to be labor-related
for purposes of the prospective payment system. As discussed in section
IV of the preamble, we are proposing to use a rebased market basket
effective for FY 1997. Based on the proposed rebased market basket, we
are revising the labor and nonlabor proportions of the standardized
amounts. Effective with discharges occurring on or after October 1,
1996, we are proposing a labor-related proportion of 71.2 percent and a
nonlabor-related proportion of 28.8 percent. The standardized amounts
in Table 1a of section V of this addendum have been recomputed to
reflect the revised labor-related and nonlabor-related proportions. (We
are revising the Puerto Rico standardized amounts by the average labor
share in Puerto Rico of 82.8 percent. We are revising the discharged-
weighted national
[[Page 27494]]
standardized amount to reflect the proportion of discharges in large
urban and other areas from the FY 1995 MedPAR file.)
2. Computing Large Urban and Other Averages Within Geographic Areas
Section 1886(d)(3) of the Act requires the Secretary to compute two
average standardized amounts for discharges occurring in a fiscal year:
one for hospitals located in large urban areas and one for hospitals
located in other areas. In addition, under sections 1886(d)(9) (B)(iii)
and (C)(i) of the Act, the average standardized amount per discharge
must be determined for hospitals located in urban and other areas in
Puerto Rico. Hospitals in Puerto Rico are paid a blend of 75 percent of
the applicable Puerto Rico standardized amount and 25 percent of a
national standardized payment amount.
Section 1886(d)(2)(D) of the Act defines ``urban areas'' as those
areas within a Metropolitan Statistical Area (MSA). A ``large urban
area'' is defined as an urban area with a population of more than
1,000,000. In addition, section 4009(i) of Public Law 100-203 provides
that a New England County Metropolitan Area (NECMA) with a population
of more than 970,000 is classified as a large urban area. As required
by section 1886(d)(2)(D) of the Act, population size is determined by
the Secretary based on the latest population data published by the
Bureau of the Census. Urban areas that do not meet the definition of a
``large urban area'' are referred to as ``other urban areas.'' Areas
that are not included in MSAs are considered ``rural areas'' under
section 1886(d)(2)(D). Payment for discharges from hospitals located in
large urban areas will be based on the large urban standardized amount.
Payment for discharges from hospitals located in other urban and rural
areas will be based on the other standardized amount.
Based on 1995 population estimates published by the Bureau of the
Census, 56 areas meet the criteria to be defined as large urban areas
for FY 1997. These areas are identified by an asterisk in Table 4a.
Table 1a contains the two national standardized amounts that we are
proposing be applicable to all hospitals, except for sole community
hospitals and hospitals in Puerto Rico. For a number of years, Table 1b
had been used to set forth the 18 regional standardized amounts
applicable for hospitals located in census areas subject to the
regional floor. However, as provided in section 1886(d)(1)(A)(iii)(II)
of the Act, the regional floor expires effective with discharges
occurring on or after October 1, 1996. Therefore, all hospitals (except
sole community hospitals and hospitals in Puerto Rico) will be paid
solely on the basis of the national standardized amounts. Under section
1886(d)(9)(A)(ii) of the Act, the national standardized payment amount
applicable to hospitals in Puerto Rico consists of the discharge-
weighted average of the national large urban standardized amount and
the national other standardized amount (as set forth in Table 1a). The
national average standardized amount for Puerto Rico is now set forth
in Table 1b. This table also includes the two standardized amounts that
would be applicable to most hospitals in Puerto Rico.
3. Updating the Average Standardized Amounts
In accordance with section 1886(d)(3)(A)(iv) of the Act, we are
proposing to update the large urban and the other areas average
standardized amounts for FY 1997 using the applicable percentage
increases specified in section 1886(b)(3)(B)(i) of the Act. Section
1886(b)(3)(B)(i)(XII) of the Act specifies that, for hospitals in all
areas, the update factor for the standardized amounts for FY 1997 is
the market basket percentage increase minus 0.5 percentage points.
The percentage change in the market basket reflects the average
change in the price of goods and services purchased by hospitals to
furnish inpatient care. The most recent forecast of the proposed
rebased hospital market basket increase for FY 1997 is 2.7 percent. For
FY 1997, this yields an update to the average standardized amounts of
2.2 percent (2.7 percent minus 0.5 percent). (See section IV of this
preamble of this proposed rule for a discussion of the market basket
rebasing.)
As in the past, we are adjusting the FY 1996 standardized amounts
to remove the effects of the FY 1996 geographic reclassifications and
outlier payments before applying the FY 1997 updates. That is, we are
increasing the standardized amounts to restore the reductions that were
made for the effects of geographic reclassification and outliers. After
including offsets to the standardized amounts for outliers and
geographic reclassification, we estimate that there will be an actual
increase of 2.3 percent to the large urban and other area standardized
amounts.
Although the update factor for FY 1997 is set by law, we are
required by section 1886(e)(3)(B) of the Act to report to Congress on
our initial recommendation of update factors for FY 1997 for both
prospective payment hospitals and hospitals excluded from the
prospective payment system. For general information purposes, we have
included the report to Congress as Appendix D to this proposed rule.
Our proposed recommendation on the update factors (which is required by
sections 1886 (e)(4)(A) and (e)(5)(A) of the Act), as well as our
responses to ProPAC's recommendation concerning the update factor, are
set forth as Appendix E to this proposed rule.
4. Other Adjustments to the Average Standardized Amounts
a. Recalibration of DRG Weights and Updated Wage Index--Budget
Neutrality Adjustment. Section 1886(d)(4)(C)(iii) of the Act specifies
that beginning in FY 1991, the annual DRG reclassification and
recalibration of the relative weights must be made in a manner that
ensures that aggregate payments to hospitals are not affected. As
discussed in section II of the preamble, we normalized the recalibrated
DRG weights by an adjustment factor, so that the average case weight
after recalibration is equal to the average case weight prior to
recalibration.
Section 1886(d)(3)(E) of the Act specifies that the hospital wage
index must be updated on an annual basis beginning October 1, 1993.
This provision also requires that any updates or adjustments to the
wage index must be made in a manner that ensures that aggregate
payments to hospitals are not affected by the change in the wage index.
To comply with the requirement of section 1886(d)(4)(C)(iii) of the
Act that DRG reclassification and recalibration of the relative weights
be budget neutral, and the requirement in section 1886(d)(3)(E) of the
Act that the updated wage index be budget neutral, we compared
aggregate payments using the FY 1996 relative weights and wage index to
aggregate payments using the proposed FY 1997 relative weights and wage
index. The same methodology was used for the FY 1996 budget neutrality
adjustment. (See the discussion in the September 1, 1992 final rule (57
FR 39832).) Based on this comparison, we computed a budget neutrality
adjustment factor equal to 0.998509. This budget neutrality adjustment
factor is applied to the standardized amounts without removing the
effects of the FY 1996 budget neutrality adjustment. We do not remove
the prior budget neutrality adjustment because estimated aggregate
payments after the changes in the DRG relative weights and wage index
should equal estimated aggregate payments prior to the changes. If we
[[Page 27495]]
removed the prior year adjustment, we would not satisfy this condition.
In addition, we are proposing to continue to apply the same FY 1997
adjustment factor to the hospital-specific rates that are effective for
cost reporting periods beginning on or after October 1, 1996, in order
to ensure that we meet the statutory requirement that aggregate
payments neither increase nor decrease as a result of the
implementation of the FY 1997 DRG weights and updated wage index. (See
the discussion in the September 4, 1990 final rule (55 FR 36073).)
b. Reclassified Hospitals--Budget Neutrality Adjustment. Section
1886(d)(8)(B) of the Act provides that certain rural hospitals are
deemed urban effective with discharges occurring on or after October 1,
1988. In addition, section 1886(d)(10) of the Act provides for the
reclassification of hospitals based on determinations by the Medicare
Geographic Classification Review Board (MGCRB). Under section
1886(d)(10) of the Act, a hospital may be reclassified for purposes of
the standardized amount or the wage index, or both.
Under section 1886(d)(8)(D) of the Act, the Secretary is required
to adjust the standardized amounts so as to ensure that total aggregate
payments under the prospective payment system after implementation of
the provisions of sections 1886(d)(8) (B) and (C) and 1886(d)(10) of
the Act are equal to the aggregate prospective payments that would have
been made absent these provisions. To calculate this budget neutrality
factor, we used historical discharge data to simulate payments, and
compared total prospective payments (including IME and DSH payments)
prior to any reclassifications to total prospective payments after
reclassifications. We are applying an adjustment factor of 0.994059 to
ensure that the effects of reclassification are budget neutral.
The adjustment factor is applied to the standardized amounts after
removing the effects of the FY 1996 budget neutrality adjustment
factor. We note that the proposed FY 1997 adjustment reflects wage
index and standardized amount reclassifications approved by the MGCRB
or the Administrator as of March 14, 1996. The effects of any
additional reclassification changes resulting from appeals and reviews
of the MGCRB decisions for FY 1997 or from a hospital's request for the
withdrawal of a reclassification request will be reflected in the final
budget neutrality adjustment required under section 1886(d)(8)(D) of
the Act and published in the final rule for FY 1997.
c. Outliers. Section 1886(d)(5)(A) of the Act provides for payments
in addition to the basic prospective payments for ``outlier'' cases,
cases involving extraordinarily high costs (cost outliers) or long
lengths of stay (day outliers). Section 1886(d)(3)(B) of the Act
requires the Secretary to adjust both the large urban and other area
national standardized amounts by the same factor to account for the
estimated proportion of total DRG payments made to outlier cases.
Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary
to adjust the large urban and other standardized amounts applicable to
hospitals in Puerto Rico by the same factor to account for the
estimated proportion of total DRG payments made to outlier cases.
Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier
payments for any year must be projected to be not less than 5 percent
nor more than 6 percent of total payments based on DRG prospective
payment rates.
Beginning with FY 1995, section 1886(d)(5)(A) of the Act requires
the Secretary to phase out payments for day outliers (correspondingly,
payments for cost outliers would increase). Under the requirements of
section 1886(d)(5)(A)(v), the proportion of day outlier payments to
total outlier payments is reduced from FY 1994 levels as follows: 75
percent of FY 1994 levels in FY 1995, 50 percent of FY 1994 levels in
FY 1996, and 25 percent of FY 1994 levels in FY 1997. We estimated the
FY 1994 proportion of day outlier payments to total outlier payments at
31.3 percent in our September 1, 1993 final rule (58 FR 46348). Thus,
the proportion of day outlier payments to total outlier payments in FY
1997 will be approximately 8 percent (25 percent of 31.3 percent). For
discharges occurring after September 30, 1997, the Secretary will no
longer pay for day outliers under the provisions of section
1886(d)(5)(A)(i) of the Act.
i. Proposed FY 1997 Outlier Payment Policies, Including Outlier
Thresholds. For FY 1996, the day outlier threshold is the geometric
mean length of stay for each DRG plus the lesser of 23 days or 3.0
standard deviations. The marginal cost factor for day outliers (the
percent of Medicare's average per diem payment paid for each outlier
day) is 44 percent for FY 1996. The fixed loss cost outlier threshold
is equal to the prospective payment for the DRG plus $15,150 ($13,800
for hospitals that have not yet entered the prospective payment system
for capital-related costs). The marginal cost factor for cost outliers
(the percent of costs paid after costs for the case exceed the
threshold) is 80 percent. We applied an outlier adjustment to the FY
1996 standardized amounts of 0.949054 for the large urban and other
areas rates and 0.9526 for the capital Federal rate.
For FY 1997, we propose to set the day outlier threshold at the
geometric mean length of stay for each DRG plus the lesser of 24 days
or 3.0 standard deviations. Section 1886(d)(5)(A)(iii) of the Act, as
amended by section 13501(c)(3) of Public Law 103-66, provides that
additional payments for day outlier cases may be reduced below the
marginal cost of care to meet the requirements of section
1886(d)(5)(A)(v) of the Act. We are proposing to reduce the marginal
cost factor for each outlier day from 44 percent to 35 percent in FY
1997. We estimate that our proposed policies will reduce the proportion
of outlier payments paid as day outliers in FY 1997 to approximately 8
percent, in accordance with section 1886(d)(5)(A) of the Act.
We are also proposing a fixed loss cost outlier threshold in FY
1997 equal to the prospective payment rate for the DRG plus $11,050
($10,075 for hospitals that have not yet entered the prospective
payment system for capital-related costs). In addition, we are
proposing to maintain the marginal cost factor for cost outliers at 80
percent.
In accordance with section 1886(d)(5)(A)(iv) of the Act, we
calculated proposed outlier thresholds so that outlier payments are
projected to equal 5.1 percent of total payments based on DRG
prospective payment rates. In accordance with section 1886(d)(3)(E), we
reduced the proposed FY 1997 standardized amounts by the same
percentage to account for the projected proportion of payments paid to
outliers.
As stated in the September 1, 1993 final rule (58 FR 46348), we
establish outlier thresholds that are applicable to both inpatient
operating costs and inpatient capital-related costs. When we modeled
the combined operating and capital outlier payments, we found that
using a common set of thresholds resulted in a higher percentage of
outlier payments for capital-related costs than for operating costs. We
project that the proposed thresholds for FY 1997 will result in outlier
payments equal to 5.1 percent of operating DRG payments and 5.2 percent
of capital payments based on the Federal rate.
Thus, the proposed outlier adjustment factors applied to the
standardized amounts and the capital Federal rate for FY 1997 are as
follows:
[[Page 27496]]
------------------------------------------------------------------------
Capital
Operating Standardized Amounts Federal
Rate
------------------------------------------------------------------------
0.948968..................................................... 0.9476
------------------------------------------------------------------------
We would apply the proposed outlier adjustment factors after
removing the effects of the FY 1996 outlier adjustment factors on the
standardized amounts and the capital Federal rate.
ii. Other Changes Concerning Outliers. Table 5 of section V of this
addendum contains the DRG relative weights, geometric and arithmetic
mean lengths of stay, as well as the day outlier threshold for each
DRG. When we recalibrate DRG weights, we set a threshold of 10 cases as
the minimum number of cases required to compute a reasonable weight and
geometric mean length of stay. DRGs that do not have at least 10 cases
are considered to be low volume DRGs. For the low volume DRGs, we use
the original geometric mean lengths of stay, because no arithmetic mean
length of stay was calculated based on the original data.
Table 8a in section V of this addendum contains the updated
Statewide average operating cost-to-charge ratios for urban hospitals
and for rural hospitals to be used in calculating cost outlier payments
for those hospitals for which the intermediary is unable to compute a
reasonable hospital-specific cost-to-charge ratio. These Statewide
average ratios would replace the ratios published in the September 1,
1995 final rule (60 FR 45922), effective October 1, 1996. Table 8b
contains comparable Statewide average capital cost-to-charge ratios.
These average ratios would be used to calculate cost outlier payments
for those hospitals for which the intermediary computes operating cost-
to-charge ratios lower than 0.24345 or greater than 1.30392 and capital
cost-to-charge ratios lower than 0.013297 or greater than 0.19968. This
range represents 3.0 standard deviations (plus or minus) from the mean
of the log distribution of cost-to-charge ratios for all hospitals. We
note that the cost-to-charge ratios in Tables 8a and 8b would be used
for all cost reports settled during FY 1997 (regardless of the actual
cost reporting period) when hospital-specific cost-to-charge ratios are
either not available or outside the three standard deviations range.
iii. FY 1995 and FY 1996 Outlier Payments. In the September 1, 1995
final rule (59 FR 45408), we stated that, based on available data, we
estimated that actual FY 1995 outlier payments would be approximately
4.0 percent of actual total DRG payments. This percentage was computed
by simulating payments using actual FY 1994 bill data available at the
time. That is, the estimate of actual outlier payments did not reflect
actual FY 1995 bills but instead reflected the application of FY 1995
rates and policies to available FY 1994 bills. Our current estimate,
using available FY 1995 bills, is that actual outlier payments for FY
1995 were approximately 3.7 percent of actual total DRG payments (lower
than the 5.1 percent we projected in setting outlier policies for FY
1995). We note that the MedPAR file for FY 1995 discharges continues to
be updated.
We currently estimate that actual outlier payments for FY 1996 will
be approximately 4.2 percent of actual total DRG payments (lower than
the 5.1 percent we projected in setting outlier policies for FY 1996).
This estimate is based on simulations using the December 1995 update of
the provider-specific file and the December 1995 update of the FY 1995
MedPAR file (discharge data for FY 1995 bills). We used these data to
calculate an estimate of the actual outlier percentage for FY 1996 by
applying FY 1996 rates and policies to available FY 1995 bills.
The following discussion addresses the methodology we use to set
outlier thresholds for an upcoming fiscal year and also addresses
possible explanations for the difference between projected and actual
outlier payment percentages in recent years.
iv. Methodology for Setting Outlier Thresholds. In previous
rulemaking documents, we have discussed the methodology for setting
outlier thresholds as well as our periodic refinements to that
methodology. In this document, we once again describe our methodology
and analyze it to suggest some possible explanations for the recent
differences between projected and actual outlier percentages. We invite
comments and suggestions for further refinements to the methodology.
In General. In accordance with section 1886(d)(5)(A)(iv) of the
Act, we set outlier thresholds so that outlier payments are expected
(projected) to equal 5.1 percent of total payments based on DRG
prospective payment rates. The databases used to calculate thresholds
for an upcoming fiscal year include data on discharges from a previous
fiscal year as well as hospital-specific data. We update the data every
year. In setting the proposed FY 1997 outlier thresholds, we used the
December 1995 update of the FY 1995 MedPAR file, which contains data on
FY 1995 hospital inpatient discharges, and the December 1995 update of
the provider-specific file, which contains information on hospital-
specific payment parameters (such as cost-to-charge ratios).
The methodology for setting outlier thresholds for an upcoming
fiscal year involves analyzing the set of hospital inpatient cases in
the MedPAR file and simulating payments for those cases by using the
payment rates and policies that would apply in the upcoming fiscal
year. For example, in calculating the proposed thresholds for FY 1997,
we used the proposed payment rates and policies for FY 1997 and
simulated payments for the set of cases in the FY 1995 MedPAR file.
The computer simulation calculates ``payments''--outlier payments
and total payments--for all discharges for a given set of outlier
thresholds. In order to achieve established objectives (for example,
the projected percentage of outlier payments relative to total DRG
payments is 5.1 percent, and the projected percentage of outlier
payments attributable to day outliers is 8 percent for FY 1997), the
methodology involves an iterative process, that is, numerous successive
simulations using alternative sets of outlier thresholds. In short,
then, the outlier estimation methodology involves analyzing historical
discharge data, simulating payments for the discharges in the database
by using the payment rates that would apply in the upcoming fiscal
year, and testing alternative sets of outlier thresholds until the
simulations are consistent with established objectives.
Cost Inflation Factors. In setting outlier thresholds for an
upcoming fiscal year, we need to calculate the ``costs'' for each case
in our database. In the payment simulations, this ``cost'' for each
case is used to determine, for a given cost outlier threshold, whether
a case qualifies for additional outlier payments and the amount of any
such payments. (As explained above, we test alternative sets of
thresholds.)
The MedPAR file includes data on billed charges, and as part of the
estimation methodology, we make adjustments to convert the charges to
costs, including adjusting the data for inflation. In setting the
proposed outlier thresholds for FY 1997, we analyzed data for FY 1995
discharges.
As we explained in the September 1, 1993 final rule (58 FR 46347),
prior to FY 1994, we used a charge inflation factor to adjust charges
to costs; for example, in setting outlier thresholds for FY 1993, we
adjusted the FY 1991 MedPAR file charge data by a charge inflation
factor for 2 years in order to estimate FY 1993 charges and then
applied the applicable cost-to-charge
[[Page 27497]]
ratio. Beginning with FY 1994, we have used a cost inflation factor to
estimate ``costs''; that is, we adjust the charges by the cost-to-
charge ratio and then adjust the resulting costs for 2 years of cost
inflation. This adjustment automatically accounts for any changes in
the cost-to-charge ratios that may occur, since the relevant variable
is the estimated ``costs'' for a given case.
In setting the final outlier thresholds for recent years
immediately prior to FY 1995, we determined cost inflation factors by
analyzing cost report information to calculate moving averages of cost
inflation for prior periods. (For example, in setting the FY 1994
outlier thresholds, we analyzed cost reports for cost reporting periods
beginning in FY 1988 through FY 1991 to calculate a cost inflation
factor, that is, the average annual increase in cost per case, of 8.3
percent.) In doing so, we made an audit adjustment for any cost report
that had not been settled, based on the average ratio of submitted to
final cost report data. In setting the final outlier thresholds for FYs
1995 and 1996, we determined cost inflation factors by analyzing cost
report information and calculating the change in cost per case for one
year, rather than the average change in cost per case over more than
one year.
In setting the proposed FY 1997 outlier thresholds, we used a cost
inflation factor of 0.0 percent, because it is unclear whether FY 1997
``costs'' will be higher or lower than costs reflected in the FY 1995
MedPAR file. Analysis of recent cost report information shows that cost
per case increased slightly for cost reporting periods beginning in FY
1993 relative to those beginning in FY 1992, but decreased slightly in
the following year (that is, for cost reporting periods beginning in FY
1994 relative to those beginning in FY 1993). We will reevaluate this
factor when we develop the final rule for FY 1997. At that time, more
recent data should be available for analysis, specifically, cost report
data for cost reporting periods beginning in FY 1995.
Differences Between Projected and Actual Outlier Percentages. As
explained above, the cost inflation factor is an important aspect of
the methodology for setting outlier thresholds, and we believe the cost
inflation factor is a major reason that in recent years the actual
outlier percentages (the proportion of actual outlier payments to
actual total DRG payments) have been lower than projected.
In determining the cost inflation factor, we analyze historical
hospital cost report information, and there is necessarily a time lag
of 2 to 3 years between the cost reporting period itself and the time
when data for that cost reporting period become available. For example,
in setting the FY 1994 outlier thresholds, we used a cost inflation
factor of 8.3 percent, derived from cost reports for cost reporting
periods beginning in FY 1988 through FY 1991. We adjusted the charges
from the FY 1992 MedPAR bills by the cost-to-charge ratio and then
adjusted the resulting FY 1992 costs for 2 years of cost inflation
(costs multiplied by 1.083 multiplied by 1.083) to estimate ``FY 1994
costs.''
However, analysis of more recent cost report information shows that
cost per case increased at a much lower rate of 0.97 percent in cost
reporting periods between FY 1992 and FY 1993 and actually decreased
1.77 percent in cost reporting periods between FY 1993 and FY 1994. In
effect, we ``overestimated'' costs by approximately 15.4 percent. Since
costs did not increase at nearly the rate we expected, actual costs in
FY 1994 proved to be lower than those reflected in the simulations used
to set the thresholds for FY 1994; accordingly, the proportion of
outlier payments was lower than expected.
Another aspect of the outlier methodology that may have contributed
to the difference between projected and actual outlier percentages
concerns the payment adjustments for indirect medical education (IME)
and disproportionate share hospitals (DSH). As indicated in previous
rulemaking documents, for purposes of determining outlier payments, we
standardize a hospital's costs for IME and DSH adjustments; that is, we
reduce the hospital's costs for a given discharge to account for IME
and DSH payments. The ``standardized'' cost for a discharge
is calculated by taking total costs for the discharge and dividing it
by the sum of one plus the hospital's DSH factor plus the hospital's
IME factor. Therefore, the higher the IME and DSH factors, the more
costs are reduced by standardization.
The factors used for purposes of setting thresholds are taken from
the most recent provider-specific file. In setting the proposed FY 1997
outlier thresholds, we used information from the December 1995 update
of the provider-specific file. We standardized the costs for each
discharge in our database to account for IME and DSH adjustments. The
proposed outlier thresholds reflect these standardized costs.
While we use the latest, most up-to-date sources of information,
the ``projected'' IME and DSH factors (the factors used to set
thresholds for a fiscal year) may differ from the actual IME and DSH
factors used to make payments in that fiscal year. If the ``projected''
factors used to standardize costs for a given discharge are ``too
low,'' then standardization does not ``sufficiently'' reduce the costs
for that discharge and the resulting standardized cost is ``too high.''
If the standardized costs for the discharges analyzed to set outlier
thresholds are generally ``too high,'' then in turn the thresholds
would be too high; consequently, this might result in a lower than
expected proportion of outlier payments. Analysis shows that, for FY
1994 for example, the ``projected'' IME and DSH factors were on average
lower than the actual factors.
Conclusion. As we have done since the inception of the prospective
payment system, we determine outlier thresholds based on estimates
before the beginning of each fiscal year. The methodology we use
involves analysis of the best data available at the time thresholds are
established; however, by their nature, projections are imprecise and
may differ from actual payment data for any number of reasons. We
discussed above some of the numerous factors that affect payment and
why these particular factors may have contributed to the difference
between projected and actual outlier payments in recent years. (See
also, for example, the discussion in the September 1, 1995 final rule
(60 FR 45855).) We note that any difference between projected and
actual outlier payment percentages in a given year does not affect
standardized amounts in future years.
We continue to explore refinements to the methodology for setting
outlier thresholds. We welcome comments and suggestions regarding these
issues.
B. Adjustments for Area Wage Levels and Cost of Living
The adjusted standardized amounts are divided into labor and
nonlabor portions. Tables 1a and 1c, as set forth in this addendum,
contain the actual labor-related and nonlabor-related shares that will
be used to calculate the prospective payment rates for hospitals
located in the 50 States, the District of Columbia, and Puerto Rico.
This section addresses two types of adjustments to the standardized
amounts that are made in determining the prospective payment rates as
described in this addendum.
1. Adjustment for Area Wage Levels
Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require
that an adjustment be made to the labor-related portion of the
prospective payment rates to account for area differences in hospital
wage levels. This
[[Page 27498]]
adjustment is made by multiplying the labor-related portion of the
adjusted standardized amounts by the appropriate wage index for the
area in which the hospital is located. In section III of the preamble,
we discuss certain revisions we are making to the wage index. This
index is set forth in Tables 4a through 4e of this addendum.
2. Adjustment for Cost of Living in Alaska and Hawaii
Section 1886(d)(5)(H) of the Act authorizes an adjustment to take
into account the unique circumstances of hospitals in Alaska and
Hawaii. Higher labor-related costs for these two States are taken into
account in the adjustment for area wages described above. For FY 1997,
we propose to adjust the payments for hospitals in Alaska and Hawaii by
multiplying the nonlabor portion of the standardized amounts by the
appropriate adjustment factor contained in the table below. If the
Office of Personnel Management releases revised cost-of-living
adjustment factors before August 1, 1996, we will publish them in the
final rule and use them in determining FY 1997 payments.
Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
------------------------------------------------------------------------
Alaska--All areas................................................ 1.25
Hawaii:
County of Honolulu............................................. 1.225
County of Hawaii............................................... 1.15
County of Kauai............................................... 1.20
County of Maui................................................. 1.225
County of Kalawao.............................................. 1.225
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office of
Personnel Management.)
C. DRG Relative Weights
As discussed in section II of the preamble, we have developed a
classification system for all hospital discharges, assigning them into
DRGs, and have developed relative weights for each DRG that reflect the
resource utilization of cases in each DRG relative to Medicare cases in
other DRGs. Table 5 of section V of this addendum contains the relative
weights that we propose to use for discharges occurring in FY 1997.
These factors have been recalibrated as explained in section II of the
preamble.
D. Calculation of Prospective Payment Rates for FY 1997
General Formula for Calculation of Prospective Payment Rates for FY
1997
Prospective payment rate for all hospitals located outside Puerto
Rico except sole community hospitals = Federal rate.
Prospective payment rate for sole community hospitals = Whichever
of the following rates yields the greatest aggregate payment: 100
percent of the Federal rate, 100 percent of the updated FY 1982
hospital-specific rate, or 100 percent of the updated FY 1987 hospital-
specific rate. Prospective payment rate for Puerto Rico = 75 percent of
the Puerto Rico rate + 25 percent of a discharge-weighted average of
the national large urban standardized amount and the national other
standardized amount.
1. Federal Rate
For discharges occurring on or after October 1, 1996 and before
October 1, 1997, except for sole community hospitals and hospitals in
Puerto Rico, the hospital's payment is based exclusively on the Federal
national rate. Section 1866(d)(1)(A)(iii) of the Act provides that the
Federal rate is comprised of 100 percent of the Federal national rate.
The payment amount is determined as follows:
Step 1--Select the appropriate national standardized amount
considering the type of hospital and designation of the hospital as
large urban or other (see Tables 1a, section V of this addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the applicable wage index for the geographic area in which
the hospital is located (see Tables 4a, 4b, and 4c, section V of this
addendum).
Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-
related portion of the standardized amount by the appropriate cost-of-
living adjustment factor.
Step 4--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount (adjusted if appropriate under Step 3).
Step 5--Multiply the final amount from Step 4 by the relative
weight corresponding to the appropriate DRG (see Table 5, section V of
this addendum).
2. Hospital-Specific Rate (Applicable Only to Sole Community Hospitals)
Sections 1886(d)(5)(D)(i) and (b)(3)(C) of the Act provide that
sole community hospitals are paid based on whichever of the following
rates yields the greatest aggregate payment: the Federal rate, the
updated hospital-specific rate based on FY 1982 cost per discharge, or
the updated hospital-specific rate based on FY 1987 cost per discharge.
Hospital-specific rates have been determined for each of these
hospitals based on both the FY 1982 cost per discharge and the FY 1987
cost per discharge. For a more detailed discussion of the calculation
of the FY 1982 hospital-specific rate and the FY 1987 hospital-specific
rate, we refer the reader to the September 1, 1983 interim final rule
(48 FR 39772); the April 20, 1990 final rule with comment (55 FR
15150); and the September 4, 1990 final rule (55 FR 35994).
a. Updating the FY 1982 and FY 1987 Hospital-Specific Rates for FY
1997. We are proposing to increase the hospital-specific rates by 2.2
percent (the hospital market basket percentage increase minus 0.5
percentage points) for sole community hospitals located in all areas in
FY 1997. Section 1886(b)(3)(C)(ii) of the Act provides that the update
factor applicable to the hospital-specific rates for sole community
hospitals equals the update factor provided under section
1886(b)(3)(B)(ii) of the Act, which, for FY 1997, is the market basket
rate of increase minus 0.5 percentage points.
b. Calculation of Hospital-Specific Rate. For sole community
hospitals, the applicable FY 1997 hospital-specific rate would be
calculated by multiplying a hospital's hospital-specific rate for the
preceding fiscal year by the applicable update factor (2.2 percent),
which is the same as the update for all prospective payment hospitals.
In addition, the hospital-specific rate would be adjusted by the budget
neutrality adjustment factor (that is, 0.998509) as discussed in
section II.A.4.a of this Addendum. This resulting rate would be used in
determining under which rate a sole community hospital is paid for its
discharges beginning on or after October 1, 1996, based on the formula
set forth above.
3. General Formula for Calculation of Prospective Payment Rates for
Hospitals Located in Puerto Rico Beginning On or After October 1, 1996
and Before October 1, 1997.
a. Puerto Rico Rate. The Puerto Rico prospective payment rate is
determined as follows:
Step 1--Select the appropriate adjusted average standardized amount
considering the large urban or other designation of the hospital (see
Table 1b, section V of the addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the appropriate wage index (see Tables 4a and 4b, section V
of the addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount.
Step 4--Multiply the result in Step 3 by 75 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5, section V of the addendum).
[[Page 27499]]
b. National Rate. The national prospective payment rate is
determined as follows:
Step 1--Multiply the labor-related portion of the national average
standardized amount (see Table 1b, section V of the addendum) by the
appropriate wage index.
Step 2--Add the amount from Step 1 and the nonlabor-related portion
of the national average standardized amount.
Step 3--Multiply the result in Step 2 by 25 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5, section V of the addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico.
III. Proposed Changes to Payment Rates for Inpatient Capital-Related
Costs for FY 1997
The prospective payment system for hospital inpatient capital-
related costs was implemented for cost reporting periods beginning on
or after October 1, 1991. Effective with that cost reporting period and
during a 10-year transition period extending through FY 2001, hospital
inpatient capital-related costs are paid on the basis of an increasing
proportion of the capital prospective payment system Federal rate and a
decreasing proportion of a hospital's historical costs for capital.
The basic methodology for determining Federal capital prospective
rates is set forth at Secs. 412.308 through 412.352. Below we discuss
the factors that we used to determine the proposed Federal rate and the
hospital-specific rates for FY 1997. The rates will be effective for
discharges occurring on or after October 1, 1996.
For FY 1992, we computed the standard Federal payment rate for
capital-related costs under the prospective payment system by updating
the FY 1989 Medicare inpatient capital cost per case by an actuarial
estimate of the increase in Medicare inpatient capital costs per case.
Each year after FY 1992 we update the standard Federal rate, as
provided in Sec. 412.308(c)(1), to account for capital input price
increases and other factors. Also, Sec. 412.308(c)(2) provides that the
Federal rate is adjusted annually by a factor equal to the estimated
proportion of outlier payments under the Federal rate to total capital
payments under the Federal rate. Section 412.308(c)(3) further requires
that the Federal rate be reduced by an adjustment factor equal to the
estimated proportion of payments for exceptions under Sec. 412.348, and
Sec. 412.308(c)(4)(ii) requires that the Federal rate be adjusted so
that the annual DRG reclassification and the recalibration of DRG
weights and changes in the geographic adjustment factor are budget
neutral. For FY 1992 through FY 1995, Sec. 412.352 required that the
Federal rate also be adjusted by a budget neutrality factor so that
aggregate payments for inpatient hospital capital costs were projected
to equal 90 percent of the payments that would have been made for
capital-related costs on a reasonable cost basis during the fiscal
year. That provision expired in FY 1996.
The hospital-specific rate for each hospital was calculated by
dividing the hospital's Medicare inpatient capital-related costs for a
specified base year by its Medicare discharges (adjusted for
transfers), and dividing the result by the hospital's case mix index
(also adjusted for transfers). The resulting case-mix adjusted average
cost per discharge was then updated to FY 1992 based on the national
average increase in Medicare's inpatient capital cost per discharge and
adjusted by the exceptions payment adjustment factor and the budget
neutrality adjustment factor to yield the FY 1992 hospital-specific
rate. The hospital-specific rate is updated each year after FY 1992 for
inflation and for changes in the exceptions payment adjustment factor.
For FY 1992 through FY 1995, the hospital-specific rate was also
adjusted by a budget neutrality adjustment factor.
To determine the appropriate budget neutrality adjustment factors
and the exceptions payment adjustment factor, we developed a dynamic
model of Medicare inpatient capital-related costs, that is, a model
that projects changes in Medicare inpatient capital-related costs over
time. With the expiration of the budget neutrality provision, the model
is still used to estimate the exceptions payment adjustment and other
factors. The model and its application are described more fully in
Appendix B.
In accordance with section 1886(d)(9)(A) of the Act, under the
prospective payment system for inpatient operating costs, hospitals
located in Puerto Rico are paid for operating costs under a special
payment formula. These hospitals are paid a blended rate that is
comprised of 75 percent of the applicable standardized amount specific
to Puerto Rico hospitals and 25 percent of the applicable national
average standardized amount. Section 412.374 provides for the use of
this blended payment system for payments to Puerto Rico hospitals under
the prospective payment system for inpatient capital-related costs.
Accordingly, for capital-related costs we compute a separate payment
rate specific to Puerto Rico hospitals using the same methodology used
to compute the national Federal rate for capital. Hospitals in Puerto
Rico are paid based on 75 percent of the Puerto Rico rate and 25
percent of the Federal rate.
A. Determination of Federal Inpatient Capital-Related Prospective
Payment Rate Update
For FY 1996, the Federal rate is $461.96. With the changes we are
proposing to the factors used to establish the Federal rate, the
proposed FY 1997 Federal rate is $441.84.
In the discussion that follows, we explain the factors that were
used to determine the proposed FY 1997 Federal rate. In particular, we
explain why the FY 1997 Federal rate has decreased 4.36 percent
compared to the FY 1996 Federal rate. Nevertheless, as explained in
section VII of Appendix A, capital payments per case are estimated to
increase 4.45 percent. Taking into account the effects of increases in
projected discharges, we also estimate that aggregate capital payments
will increase 7.28 percent.
The major factor contributing to the decrease in the proposed FY
1997 rate in comparison to the FY 1996 rate is the change in the
exceptions reduction factor. We have expected the number and amount of
exceptions payments generally to increase throughout the transition
period.
Total payments to hospitals under the prospective payment system
are relatively insensitive to changes in the capital prospective
payments. Since capital payments constitute about 10 percent of
hospital payments, a 1 percent change in the capital Federal rate
yields only about 0.1 percent change in actual payments to hospitals.
Aggregate payments under the capital prospective payment transition
system are estimated to increase in FY 1997 compared to FY 1996.
Specifically, we estimate that aggregate payments in FY 1997 will be
7.28 percent higher than they were in FY 1996. Changes in aggregate
payments include changes in capital payments per discharge and changes
in the number of discharges. Under the prospective payment system for
capital-related costs, payments per discharge (or case) are estimated
to increase 4.45 percent in FY 1997 compared to FY 1996.
1. Standard Federal Rate Update
Section 412.308(c)(1) has provided that the standard Federal rate
is updated on the basis of an analytical framework
[[Page 27500]]
that takes into account changes in a capital input price index and
other factors. The update framework consists of a capital input price
index (CIPI) and several policy adjustment factors. Specifically, we
have adjusted the projected CIPI rate of increase as appropriate each
year for case-mix index related changes, for intensity, and for errors
in previous CIPI forecasts. The proposed update factor for FY 1997
under that framework is 1.0 percent. This proposal is based on a
projected 1.0 percent increase in the CIPI, and on policy adjustment
factors of zero. We explain the basis for the FY 1997 CIPI projection
in section IV.B of the preamble to this proposed rule. Here we describe
the policy adjustments that have been applied.
The case-mix index (CMI) is the measure of the average DRG weight
for cases paid under the prospective payment system. Because the DRG
weight determines the prospective payment for each case, any percentage
increase in the CMI corresponds to an equal percentage increase in
hospital payments.
The CMI can change for any of several reasons: because the average
resource use of Medicare patients changes (``real'' case-mix change);
because changes in hospital coding of patient records result in higher
weight DRG assignments (``coding effects''); and because the annual DRG
reclassification and recalibration changes may not be budget neutral
(``reclassification effect''). We define real case-mix change as actual
changes in the mix (and resource requirements) of Medicare patients as
opposed to changes in coding behavior that result in assignment of
cases to higher-weighted DRGs but do not reflect higher resource
requirements. In the update framework for the prospective payment
system for operating costs, we adjust the update upwards to allow for
real case-mix change, but remove the effects of coding changes on the
CMI. We also remove the effect on total payments of prior changes to
the DRG classifications and relative weights, in order to retain budget
neutrality for all CMI-related changes other than patient severity.
(For example, we adjusted for the effects of the FY 1992 DRG
reclassification and recalibration as part of our FY 1994 update
recommendation.) The operating adjustment consists of a reduction for
total observed case-mix change, an increase for the portion of case-mix
change that we determine is due to real case-mix change rather than
coding modifications, and an adjustment for the effect of prior DRG
reclassification and recalibration changes. We have adopted this CMI
adjustment in the capital update framework as well.
For FY 1997, we are projecting a 1.6 percent increase in the case-
mix index. We estimate that real case-mix increase will equal projected
case-mix increase in FY 1997. We do not anticipate any changes in
coding behavior in our projected case-mix change. We explain the basis
for this determination in Appendix D to this proposed rule. The
proposed net adjustment for case-mix change in FY 1997 is therefore 0.0
percentage points.
We estimate that DRG reclassification and recalibration resulted in
a 0.0 percent change in the case mix when compared with the case-mix
index that would have resulted if we had not made the reclassification
and recalibration changes to the DRGs.
The current operating update framework contains an adjustment for
forecast error. The input price index forecast is based on historical
trends and relationships ascertainable at the time the update factor is
established for the upcoming year. In any given year there may be
unanticipated price fluctuations that may result in differences between
the actual increase in prices faced by hospitals and the forecast used
in calculating the update factors. In setting a prospective payment
rate under the proposed framework, we make an adjustment for forecast
error only if our estimate of the capital input price index rate of
increase for any year is off by 0.25 percentage points or more. There
is a 2-year lag between the forecast and the measurement of the
forecast error. Thus, for example, we would adjust for a forecast error
made in FY 1996 through an adjustment to the FY 1998 update. Because we
only introduced this analytical framework in FY 1996, FY 1998 is the
first year in which a forecast error adjustment could be required.
Under the capital prospective payment system framework, we also
make an adjustment for changes in intensity. We calculate this
adjustment using the same methodology and data as in the framework for
the operating prospective payment system. The intensity factor for the
operating update framework reflects how hospital services are utilized
to produce the final product, that is, the discharge. This component
accounts for changes in the use of quality-enhancing services, changes
in within-DRG severity, and expected modification of practice patterns
to remove cost-ineffective services.
We calculate case-mix constant intensity as the change in total
charges per admission, adjusted for price level changes (the CPI
hospital component) and changes in real case mix. The use of total
charges in the calculation of the proposed intensity factor makes it a
total intensity factor, that is, charges for capital services are
already built into the calculation of the factor. We have therefore
incorporated the intensity adjustment from the operating update
framework into the capital update framework. In the absence of reliable
estimates of the proportions of the overall annual intensity increases
that are due, respectively, to ineffective practice patterns and to the
combination of quality-enhancing new technologies and within-DRG
complexity, we assume, as in the revised operating update framework,
that one-half of the annual increase is due to each of these factors.
The capital update framework thus provides an add-on to the input price
index rate of increase of one-half of the estimated annual increase in
intensity to allow for within-DRG severity increases and the adoption
of quality-enhancing technology.
For FY 1997, we have developed a Medicare-specific intensity
measure based on a five-year average using FY 1991-1995. In determining
case-mix constant intensity, we found that observed case-mix increase
was 2.8 percent in FY 1991, 1.8 percent in FY 1992, 0.9 percent in FY
1993, 0.8 percent in FY 1994, and 1.6 percent in FY 1995. For FY 1991
and FY 1992, we estimate that real case-mix increase was 1.0 to 1.4
percent each year. The estimate for those years is supported by past
studies of case-mix change by the RAND Corporation. The most recent
study was ``Has DRG Creep Crept Up? Decomposing the Case Mix Index
Change Between 1987 and 1988'' by G.M. Carter, J.P. Newhouse, and D.A.
Relles, R-4098-HCFA/ProPAC (1991). The study suggested that real case-
mix change was not dependent on total change, but was rather a fairly
steady 1.0 to 1.5 percent per year. We use 1.4 percent as the upper
bound because the RAND study did not take into account that hospitals
may have induced doctors to document medical records more completely in
order to improve payment. Following that study, we consider up to 1.4
percent of observed case-mix change as real for FY 1991 through FY
1994. As discussed above, we have determined that all of the observed
case-mix increase for FY 1995 is real.
Given estimates of real case-mix increase of 1.0 percent for FY
1991 and FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, and
1.6 percent for FY 1995, we estimate that case-mix constant intensity
declined by an
[[Page 27501]]
average 1.1 percent during FY 1991 through FY 1995, for a cumulative
decrease of 5.6 percent. If we assume that real case-mix increase was
1.4 percent for FY 1991 and FY 1992, 0.9 percent for FY 1993, 0.8
percent for FY 1994, and 1.6 percent for FY 1995, we estimate that
case-mix constant intensity declined by an average 1.2 percent during
FY 1991 through FY 1995, for a cumulative decrease of 5.9 percent.
Since we estimate that intensity has declined during that period, we
are recommending a 0.0 percent intensity adjustment for FY 1997.
2. Outlier Payment Adjustment Factor
Section 412.312(c) establishes a unified outlier methodology for
inpatient operating and inpatient capital-related costs. A single set
of thresholds is used to identify outlier cases for both inpatient
operating and inpatient capital-related payments. Outlier payments are
made only on the portion of the Federal rate that is used to calculate
the hospital's inpatient capital-related payments (for example, 60
percent for cost reporting periods beginning in FY 1997 for hospitals
paid under the fully prospective methodology). Section 412.308(c)(2)
provides that the standard Federal rate for inpatient capital-related
costs be reduced by an adjustment factor equal to the estimated
proportion of outlier payments under the Federal rate to total
inpatient capital-related payments under the Federal rate. The outlier
thresholds are set so that operating outlier payments are projected to
be 5.1 percent of total operating DRG payments. The inpatient capital-
related outlier reduction factor reflects the inpatient capital-related
outlier payments that would be made if all hospitals were paid
according to 100 percent of the Federal rate. For purposes of
calculating the outlier thresholds and the outlier reduction factor, we
model all hospitals as if paid 100 percent of the Federal rate because,
as explained above, outlier payments are made only on the portion of
the Federal rate that is included in the hospital's inpatient capital-
related payments.
In the September 1, 1995 final rule, we estimated that outlier
payments for capital in FY 1996 would equal 4.64 percent of inpatient
capital-related payments based on the Federal rate. Accordingly, we
applied an outlier adjustment factor of 0.9536 to the Federal rate.
Based on the thresholds as set forth in section II.A.4.d of this
Addendum, we estimate that outlier payments for capital will equal 5.24
percent of inpatient capital-related payments based on the Federal rate
in FY 1997. We are, therefore, proposing an outlier adjustment factor
of 0.9476 to the Federal rate. Thus, estimated capital outlier payments
for FY 1997 represent a higher percentage of total capital standard
payments than in FY 1996.
The outlier reduction factors are not built permanently into the
rates; that is, they are not applied cumulatively in determining the
Federal rate. Therefore, the proposed net change in the outlier
adjustment to the Federal rate for FY 1997 is 0.9937 (0.9476/0.9536).
Thus, the outlier adjustment decreases the FY 1997 Federal rate by 0.63
percent (0.9937 - 1) compared with the FY 1996 outlier adjustment.
3. Budget Neutrality Adjustment Factor for Changes in DRG
Classifications and Weights and the Geographic Adjustment Factor
Section 412.308(c)(4)(ii) requires that the Federal rate be
adjusted so that aggregate payments for the fiscal year based on the
Federal rate after any changes resulting from the annual DRG
reclassification and recalibration and changes in the geographic
adjustment factor are projected to equal aggregate payments that would
have been made on the basis of the Federal rate without such changes.
We use the actuarial model described in Appendix B to estimate the
aggregate payments that would have been made on the basis of the
Federal rate without changes in the DRG classifications and weights and
in the geographic adjustment factor. We also use the model to estimate
aggregate payments that would be made on the basis of the Federal rate
as a result of those changes. We then use these figures to compute the
adjustment required to maintain budget neutrality for changes in DRG
weights and in the geographic adjustment factor.
For FY 1996, we calculated a GAF/DRG budget neutrality factor of
0.9994. For FY 1997, we are proposing a GAF/DRG budget neutrality
factor of 0.9992. The GAF/DRG budget neutrality factors are built
permanently into the rates; that is, they are applied cumulatively in
determining the Federal rate. This follows from the requirement that
estimated aggregate payments each year be no more than they would have
been in the absence of the annual DRG reclassification and
recalibration and changes in the geographic adjustment factor. The
proposed incremental change in the adjustment from FY 1996 to FY 1997
is 0.9992. The proposed cumulative change in the rate due to this
adjustment is 1.0017 (the product of the incremental factors for FY
1993, FY 1994, FY 1995, FY 1996 and the proposed incremental factor for
FY 1997: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9992 = 1.0017).
This factor accounts for DRG reclassifications and recalibration
and for changes in the geographic adjustment factor. It also
incorporates the effects on the geographic adjustment factor of FY 1997
geographic reclassification decisions made by the MGCRB compared to FY
1996 decisions. However, it does not account for changes in payments
due to changes in the disproportionate share and indirect medical
education adjustment factors or in the large urban add-on.
4. Exceptions Payment Adjustment Factor
Section 412.308(c)(3) requires that the standard Federal rate for
inpatient capital-related costs be reduced by an adjustment factor
equal to the estimated proportion of additional payments for exceptions
under Sec. 412.348 relative to total payments under the hospital-
specific rate and Federal rate. We use the model originally developed
for determining the budget neutrality adjustment factor to determine
the exceptions payment adjustment factor. We describe that model in
Appendix B to this proposed rule.
For FY 1996, we estimated that exceptions payments would equal 1.51
percent of aggregate payments based on the Federal rate and the
hospital-specific rate. Therefore, we applied an exceptions reduction
factor of 0.9849 (1-0.0151) in determining the Federal rate. For this
proposed rule, we estimate that exceptions payments for FY 1997 will
equal 6.07 percent of aggregate payments based on the Federal rate and
the hospital-specific rate. We are, therefore, proposing an exceptions
payment reduction factor of 0.9393 to the Federal rate for FY 1997.
The proposed exceptions reduction factor for FY 1997 is thus 4.63
percent lower than the factor for FY 1996. We have expected the number
and amount of exceptions payments generally to increase throughout the
transition period.
The exceptions reduction factors are not built permanently into the
rates; that is, the factors are not applied cumulatively in determining
the Federal rate. Therefore, the proposed net adjustment to the FY 1997
Federal rate is 0.9393/0.9849, or 0.9537.
5. Standard Capital Federal Rate for FY 1997
For FY 1996, the capital Federal rate was $461.96. With the changes
we are proposing to the factors used to establish the Federal rate, the
FY 1997
[[Page 27502]]
Federal rate would be $441.84. The proposed Federal rate for FY 1997
was calculated as follows:
The proposed FY 1997 update factor is 1.0100, that is, the
proposed update is 1.00 percent.
The proposed FY 1997 budget neutrality adjustment factor
that is applied to the standard Federal payment rate for changes in the
DRG relative weights and in the geographic adjustment factor is 0.9992.
The proposed FY 1997 outlier adjustment factor is 0.9476.
The proposed FY 1997 exceptions payments adjustment factor
is 0.9393.
Since the Federal rate has already been adjusted for differences in
case mix, wages, cost of living, indirect medical education costs, and
payments to hospitals serving a disproportionate share of low-income
patients, we propose to make no additional adjustments in the standard
Federal rate for these factors other than the budget neutrality factor
for changes in the DRG relative weights and the geographic adjustment
factor.
We are providing a chart that shows how each of the factors and
adjustments for FY 1997 affected the computation of the proposed FY
1997 Federal rate in comparison to the FY 1996 Federal rate. The
proposed FY 1997 update factor has the effect of increasing the Federal
rate by 1.00 percent compared to the rate in FY 1996, while the
proposed geographic and DRG budget neutrality factor has the effect of
decreasing the Federal rate by 0.08 percent. The proposed FY 1997
outlier adjustment factor has the effect of decreasing the Federal rate
by 0.63 percent compared to FY 1996. The proposed FY 1997 exceptions
reduction factor has the effect of decreasing the Federal rate by 4.63
percent compared to the exceptions reduction for FY 1996. The combined
effect of all the proposed changes is to decrease the proposed Federal
rate by 4.36 percent compared to the Federal rate for FY 1996.
Comparison of Factors and Adjustments: FY 1996 Federal Rate and Proposed FY 1997 Federal Rate
----------------------------------------------------------------------------------------------------------------
Percent
Change change
----------------------------------------------------------------------------------------------------------------
Update factor: \1\
FY 1996.................................................................... 1.0120 ......... .........
Proposed FY 1997........................................................... 1.0100 1.0100 1.00
GAF/DRG adjustment factor \1\ .........
FY 1996.................................................................... 0.9994 ......... .........
Proposed FY 1997........................................................... 0.9992 0.9992 -0.08
Outlier adjustment factor: \2\
FY 1996.................................................................... 0.9536 ......... .........
Proposed FY 1997........................................................... 0.9476 0.9937 -0.63
Exceptions adjustment factor: \2\
FY 1996.................................................................... 0.9849 ......... .........
Proposed FY 1997........................................................... 0.9393 0.9537 -4.63
Federal Rate:
FY 1996.................................................................... $461.96 ......... .........
Proposed FY 1997........................................................... $441.84 0.9564 -4.36
----------------------------------------------------------------------------------------------------------------
\1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for
example, the incremental change from FY 1996 to FY 1997 resulting from the application of the 0.9992 GAF/DRG
budget neutrality factor for FY 1997 is 0.9992.
\2\ The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates;
that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net
change resulting from the application of the FY 1997 exceptions reduction factor is 0.9393/0.9849, or 0.9537.
6. Special Rate for Puerto Rico Hospitals
For FY 1996, the special rate for Puerto Rico hospitals was
$355.35. With the changes we are proposing to the factors used to
determine the rate, the proposed FY 1997 special rate for Puerto Rico
would be $339.87.
B. Determination of Hospital-Specific Rate Update
Section 412.328(e) of the regulations provides that the hospital-
specific rate for FY 1997 be determined by adjusting the FY 1996
hospital-specific rate by the following factors:
1. Hospital-Specific Rate Update Factor
The hospital-specific rate is updated in accordance with the update
factor for the standard Federal rate determined under
Sec. 412.308(c)(1). For FY 1997, we are proposing that the hospital-
specific rate be updated by a factor of 1.0100.
2. Exceptions Payment Adjustment Factor
For FY 1992 through FY 2001, the updated hospital-specific rate is
multiplied by an adjustment factor to account for estimated exceptions
payments for capital-related costs under Sec. 412.348, determined as a
proportion of the total amount of payments under the hospital-specific
rate and the Federal rate. For FY 1997, we estimate that exceptions
payments will be 6.07 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. We therefore propose that
the updated hospital-specific rate be reduced by a factor of 0.9393.
The exceptions reduction factors are not built permanently into the
rates; that is, the factors are not applied cumulatively in determining
the hospital-specific rate. Therefore, the proposed net adjustment to
the FY 1997 hospital-specific rate is 0.9393/0.9849, or 0.9537.
3. Net Change to Hospital-Specific Rate
We are providing a chart to show the net change to the hospital-
specific rate. The chart shows the factors for FY 1996 and FY 1997 and
the net adjustment for each factor. It also shows that the proposed
cumulative net adjustment from FY 1996 to FY 1997 is 0.9632, which
represents a proposed decrease of 3.68 percent to the hospital-specific
rate. The proposed FY 1997 hospital-specific rate for each hospital is
determined by multiplying the FY 1996 hospital-specific rate by the
cumulative net adjustment of 0.9632.
[[Page 27503]]
Proposed FY 1997 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
Net Percent
adjustment change
----------------------------------------------------------------------------------------------------------------
Update factor:
FY 1996................................................................... 1.0120 .......... .........
Proposed FY 1997.......................................................... 1.0100 1.0100 1.00
Exceptions payment adjustment factor:
FY 1996................................................................... 0.9849 .......... .........
Proposed FY 1997.......................................................... 0.9393 0.9537 -4.63
Cumulative adjustments:
FY 1996................................................................... 0.9967 .......... .........
Proposed FY 1997.......................................................... 0.9601 0.9632 -3.68
----------------------------------------------------------------------------------------------------------------
Note: The update factor for the hospital-specific rate is applied cumulatively in determining the rates. Thus,
the incremental increase in the update factor from FY 1996 to FY 1997 is 1.0100. In contrast, the exceptions
payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the
exceptions reduction factor from FY 1996 to FY 1997 is 0.9393/0.9849, or 0.9537.
C. Calculation of Inpatient Capital-Related Prospective Payments for FY
1997
During the capital prospective payment system transition period, a
hospital is paid for the inpatient capital-related costs under one of
two alternative payment methodologies: the fully prospective payment
methodology or the hold-harmless methodology. The payment methodology
applicable to a particular hospital is determined when a hospital comes
under the prospective payment system for capital-related costs by
comparing its hospital-specific rate to the Federal rate applicable to
the hospital's first cost reporting period under the prospective
payment system. The applicable Federal rate was determined by making
adjustments as follows:
For outliers by dividing the standard Federal rate by the
outlier reduction factor for that fiscal year; and,
For the payment adjustment factors applicable to the
hospital (that is, the hospital's geographic adjustment factor, the
disproportionate share adjustment factor, and the indirect medical
education adjustment factor, when appropriate).
If the hospital-specific rate is above the applicable Federal rate,
the hospital is paid under the hold-harmless methodology. If the
hospital-specific rate is below the applicable Federal rate, the
hospital is paid under the fully prospective methodology.
For purposes of calculating payments for each discharge under both
the hold-harmless payment methodology and the fully prospective payment
methodology, the standard Federal rate is adjusted as follows:
(Standard Federal Rate) x (DRG weight) x (Geographic Adjustment
Factor) x (Large Urban Add-on, if applicable) x (COLA adjustment for
hospitals located in Alaska and Hawaii) x (1+Disproportionate Share
Adjustment Factor+Indirect Medical Education Adjustment Factor, if
applicable). The result is termed the adjusted Federal rate.
Payments under the hold-harmless methodology are determined under
one of two formulas. A hold-harmless hospital is paid the higher of:
100 percent of the adjusted Federal rate for each
discharge; or
An old capital payment equal to 85 percent (100 percent
for sole community hospitals) of the hospital's allowable Medicare
inpatient old capital costs per discharge for the cost reporting period
plus a new capital payment based on a percentage of the adjusted
Federal rate for each discharge. The percentage of the adjusted Federal
rate equals the ratio of the hospital's allowable Medicare new capital
costs to its total Medicare inpatient capital-related costs in the cost
reporting period.
Once a hospital receives payment based on 100 percent of the
adjusted Federal rate in a cost reporting period beginning on or after
October 1, 1994 (or the first cost reporting period after obligated
capital that is recognized as old capital under Sec. 412.302(c) is put
in use for patient care, if later), the hospital continues to receive
capital prospective payment system payments on that basis for the
remainder of the transition period.
Payment for each discharge under the fully prospective methodology
is the sum of:
The hospital-specific rate multiplied by the DRG relative
weight for the discharge and by the applicable hospital-specific
transition blend percentage for the cost reporting period; and
The adjusted Federal rate multiplied by the Federal
transition blend percentage.
The blend percentages for cost reporting periods beginning in FY
1997 are 60 percent of the adjusted Federal rate and 40 percent of the
hospital-specific rate.
Hospitals may also receive outlier payments for those cases that
qualify under the thresholds established for each fiscal year. Section
412.312(c) provides for a single set of thresholds to identify outlier
cases for both inpatient operating and inpatient capital-related
payments. Outlier payments are made only on that portion of the Federal
rate that is used to calculate the hospital's inpatient capital-related
payments. For fully prospective hospitals, that portion is 60 percent
of the Federal rate for discharges occurring in cost reporting periods
beginning during FY 1997. Thus, a fully prospective hospital will
receive 60 percent of the capital-related outlier payment calculated
for the case for discharges occurring in cost reporting periods
beginning in FY 1997. For hold-harmless hospitals paid 85 percent of
their reasonable costs for old inpatient capital, the portion of the
Federal rate that is included in the hospital's outlier payments is
based on the hospital's ratio of Medicare inpatient costs for new
capital to total Medicare inpatient capital costs. For hold-harmless
hospitals that are paid 100 percent of the Federal rate, 100 percent of
the Federal rate is included in the hospital's outlier payments.
The proposed outlier thresholds for FY 1997 are published in
section II.A.4.c of this Addendum. For FY 1997, a case qualifies as a
cost outlier if the cost for the case (after standardization for the
indirect teaching adjustment and disproportionate share adjustment) is
greater than the prospective payment rate for the DRG plus $11,050. A
case qualifies as a day outlier for FY 1997 if the length of stay is
greater than the geometric mean length of stay for the DRG plus the
lesser of 24 days or three standard deviations of the length of stay.
During the capital prospective payment system transition period, a
hospital may also receive an additional payment under an exceptions
process if its total inpatient capital-related
[[Page 27504]]
payments are less than a minimum percentage of its allowable Medicare
inpatient capital-related costs. The minimum payment level is
established by class of hospital under Sec. 412.348. The proposed
minimum payment levels for portions of cost reporting periods occurring
in FY 1997 are:
Sole community hospitals (located in either an urban or
rural area), 90 percent;
Urban hospitals with at least 100 beds and a
disproportionate share patient percentage of at least 20.2 percent and
urban hospitals with at least 100 beds that qualify for
disproportionate share payments under Sec. 412.106(c)(2), 80 percent;
and,
All other hospitals, 70 percent.
Under Sec. 412.348(d), the amount of the exceptions payment is
determined by comparing the cumulative payments made to the hospital
under the capital prospective payment system to the cumulative minimum
payment levels applicable to the hospital for each cost reporting
period subject to that system. Any amount by which the hospital's
cumulative payments exceed its cumulative minimum payment is deducted
from the additional payment that would otherwise be payable for a cost
reporting period.
New hospitals are exempted from the capital prospective payment
system for their first 2 years of operation and are paid 85 percent of
their reasonable costs during that period. A new hospital's old capital
costs are its allowable costs for capital assets that were put in use
for patient care on or before the later of December 31, 1990 or the
last day of the hospital's base year cost reporting period, and are
subject to the rules pertaining to old capital and obligated capital as
of the applicable date. Effective with the third year of operation, we
will pay the hospital under either the fully prospective methodology,
using the appropriate transition blend in that Federal fiscal year, or
the hold-harmless methodology. If the hold-harmless methodology is
applicable, the hold-harmless payment for assets in use during the base
period would extend for 8 years, even if the hold-harmless payments
extend beyond the normal transition period.
V. Tables
This section contains the tables referred to throughout the
preamble to this proposed rule and in this Addendum. For purposes of
this proposed rule, and to avoid confusion, we have retained the
designations of Tables 1 through 5 that were first used in the
September 1, 1983 initial prospective payment final rule (48 FR 39844).
Tables 1a, 1c, 1d, 3C, 4a, 4b, 4c, 4d, 4e, 5, 6A, 6B, 6C, 6D, 6E, 6F,
6G, 6H, 7A, 7B, 8A, and 8B are presented below. The tables presented
below are as follows:
Table 1a--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1c--Adjusted Operating Standardized Amounts for Puerto Rico,
Labor/Nonlabor
Table 1d--Capital Standard Federal Payment Rate
Table 3C--Hospital Case Mix Indexes for Discharges Occurring in
Federal Fiscal Year 1995 and Hospital Average Hourly Wage for
Federal Fiscal Year 1997 Wage Index
Table 4a--Wage Index and Capital Geographic Adjustment Factor (GAF)
for Urban Areas
Table 4b--Wage Index and Capital Geographic Adjustment Factor (GAF)
for Rural Areas
Table 4c--Wage Index and Capital Geographic Adjustment Factor (GAF)
for Hospitals That Are Reclassified
Table 4d--Average Hourly Wage for Urban Areas
Table 4e--Average Hourly Wage for Rural Areas
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting
Factors, Geometric Mean Length of Stay, and Length of Stay Outlier
Cutoff Points Used in the Prospective Payment System
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Invalid Procedure Codes
Table 6E--Revised Diagnosis Code Titles
Table 6F--Revised Procedure Code Titles
Table 6G--Additions to the CC Exclusions List
Table 6H--Deletions to the CC Exclusions List
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 95 MEDPAR Update 12/95 GROUPER V13.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 95 MEDPAR Update 12/95 GROUPER V14.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for
Urban and Rural Hospitals (Case Weighted) April 1996
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) April 1996
Table 1a.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
------------------------------------------------------------------------
Non-labor Non-labor
Labor-related related Labor-related related
------------------------------------------------------------------------
2796.66.......... 1131.23 2752.39 1113.33
------------------------------------------------------------------------
Table 1c.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------
Labor- Non-labor Labor- Non-labor
related related related related
----------------------------------------------------------------------------------------------------------------
National.................................................... $2772.89 $1121.62 $2772.89 $1121.62
Puerto Rico................................................. 2501.07 521.22 2461.47 512.97
----------------------------------------------------------------------------------------------------------------
Table 1d.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National..................................................... $441.84
Puerto Rico.................................................. 339.87
------------------------------------------------------------------------
[[Page 27505]]
Table 3c.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1995
Page 1 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
010001....................... 01.4400 14.82 010095.......... 00.9230 11.25 030004......... 00.9824 13.49 040004......... 01.4485 14.83 040107......... 01.1923 14.95
010004....................... 00.9600 11.10 010097.......... 00.9405 15.20 030006......... 01.5576 17.52 040005......... 01.0380 11.59 040109......... 01.1692 12.69
010005....................... 01.1609 15.40 010098.......... 01.1941 11.02 030007......... 01.3158 16.41 040007......... 01.8761 18.12 040114......... 01.8513 16.64
010006....................... 01.4752 15.23 010099.......... 01.1210 15.49 030008......... 02.1095 20.42 040008......... 01.0325 10.77 040116......... 01.3895 19.25
010007....................... 01.0986 13.12 010100.......... 01.1688 14.77 030009......... 01.2993 15.58 040010......... 01.2298 13.78 040118......... 01.1313 14.29
010008....................... 01.1366 09.54 010101.......... 01.1127 14.21 030010......... 01.4160 17.75 040011......... 00.9298 10.75 040119......... 01.0914 14.34
010009....................... 01.1377 14.82 010102.......... 00.9529 13.63 030011......... 01.4747 17.66 040014......... 01.1929 16.07 040124......... 01.2238 14.30
010010....................... 01.1330 14.33 010103.......... 01.7534 17.01 030012......... 01.2246 15.81 040015......... 01.1944 12.12 040126......... 00.9617 11.74
010011....................... 01.6185 18.94 010104.......... 01.6892 17.87 030013......... 01.2459 18.99 040016......... 01.7330 16.43 050002......... 01.5554 25.91
010012....................... 01.2666 16.27 010108.......... 01.1189 13.68 030014......... 01.4394 17.86 040017......... 01.2569 11.68 050006......... 01.3983 19.15
010015....................... 01.0512 15.63 010109.......... 01.0527 11.48 030016......... 01.2462 17.09 040018......... 01.1686 16.66 050007......... 01.5848 25.29
010016....................... 01.2643 16.76 010110.......... 01.0168 13.44 030017......... 01.4929 18.98 040019......... 01.1618 13.52 050008......... 01.4998 25.48
010018....................... 00.9017 16.19 010112.......... 01.1253 14.09 030018......... 01.7989 19.57 040020......... 01.5987 14.08 050009......... 01.7211 31.63
010019....................... 01.2868 14.99 010113.......... 01.6374 13.69 030019......... 01.1962 19.31 040021......... 01.2277 14.69 050013......... 01.8099 22.05
010021....................... 01.2388 12.20 010114.......... 01.3174 15.37 030022......... 01.5055 17.41 040022......... 01.6951 14.73 050014......... 01.1741 22.55
010022....................... 01.0109 16.89 010115.......... 00.8385 11.98 030023......... 01.2640 17.64 040024......... 01.1709 12.16 050015......... 01.3882 22.18
010023....................... 01.4760 14.71 010117.......... 00.7880 13.54 030024......... 01.7809 21.04 040025......... 00.9214 11.81 050016......... 01.1598 18.51
010024....................... 01.4014 15.62 010118.......... 01.2475 15.07 030025......... 01.1633 12.76 040026......... 01.5547 16.35 050017......... 02.0618 24.39
010025....................... 01.4390 13.16 010119.......... 01.5429 16.36 030027......... 01.0875 14.69 040027......... 01.2889 12.56 050018......... 01.3434 18.49
010027....................... 00.8352 13.55 010120.......... 00.9668 14.32 030030......... 01.6651 18.19 040028......... 01.0903 11.40 050021......... 01.4146 23.75
010029....................... 01.4957 14.84 010121.......... 01.2269 12.92 030033......... 01.2475 16.40 040029......... 01.2557 14.12 050022......... 01.4601 22.63
010031....................... 01.1808 14.58 010123.......... 01.2421 17.47 030034......... 01.0430 15.89 040030......... 00.8925 11.09 050024......... 01.3952 21.31
010032....................... 00.9478 12.45 010124.......... 01.2927 16.15 030035......... 01.3403 20.77 040032......... 01.0056 11.18 050025......... 01.8000 22.00
010033....................... 01.9143 17.61 010125.......... 01.0247 12.86 030036......... 01.1393 18.23 040035......... 01.0240 10.24 050026......... 01.4525 21.79
010034....................... 01.0751 13.48 010126.......... 01.1770 13.13 030037......... 02.0161 19.60 040036......... 01.4976 16.45 050028......... 01.4395 15.33
010035....................... 01.2397 15.13 010127.......... 01.2999 16.29 030038......... 01.6125 18.82 040037......... 01.1101 11.55 050029......... 01.3830 25.55
010036....................... 01.1252 15.34 010128.......... 00.9565 12.34 030040......... 01.1885 15.88 040039......... 01.2411 12.23 050030......... 01.3324 19.24
010038....................... 01.3397 16.48 010129.......... 01.0795 13.29 030041......... 00.9963 13.68 040040......... 00.9953 15.73 050032......... 01.2735 22.76
010039....................... 01.7029 16.14 010130.......... 01.0352 15.28 030043......... 01.1937 18.25 040041......... 01.3946 13.95 050033......... 01.4136 25.47
010040....................... 01.5335 18.21 010131.......... 01.3636 17.75 030044......... 01.0291 13.19 040042......... 01.2978 12.03 050036......... 01.6162 18.61
010043....................... 01.1036 10.35 010134.......... 00.9206 13.36 030046......... 00.9134 16.38 040044......... 00.9622 10.04 050038......... 01.4553 29.05
010044....................... 01.0919 11.01 010137.......... 01.2516 16.36 030047......... 00.9471 19.91 040045......... 01.0301 14.28 050039......... 01.6127 21.04
010045....................... 01.2121 10.79 010138.......... 00.9485 09.85 030049......... 00.9741 17.30 040047......... 01.0939 14.78 050040......... 01.0842 22.92
010046....................... 01.5291 15.51 010139.......... 01.6592 19.67 030054......... 00.8723 12.63 040048......... 01.2149 13.48 050041......... 02.8656 22.21
010047....................... 01.0243 10.05 010143.......... 01.1921 15.83 030055......... 01.2014 16.85 040050......... 01.1013 11.66 050042......... 01.3081 20.20
010049....................... 01.1121 15.66 010144.......... 01.3104 18.42 030059......... 01.2776 19.95 040051......... 01.0923 12.64 050043......... 01.5723 30.15
010050....................... 01.0635 13.48 010145.......... 01.3376 14.59 030060......... 01.2095 13.90 040053......... 01.1093 11.67 050045......... 01.2649 17.11
010051....................... 00.8549 10.24 010146.......... 01.1772 15.59 030061......... 01.6462 16.75 040054......... 01.0301 12.44 050046......... 01.1888 23.81
010052....................... 00.9858 12.78 010148.......... 00.9969 12.83 030062......... 01.2267 15.56 040055......... 01.4506 14.51 050047......... 01.6388 29.15
010053....................... 01.0653 12.67 010149.......... 01.3527 17.75 030064......... 01.6191 16.92 040058......... 01.0617 13.61 050051......... 01.1104 16.63
010054....................... 01.1726 16.17 010150.......... 01.0473 16.29 030065......... 01.6407 18.87 040060......... 00.9896 09.85 050054......... 01.1961 20.55
010055....................... 01.4846 16.35 010152.......... 01.4762 16.29 030067......... 01.0515 15.92 040062......... 01.6181 16.66 050055......... 01.3742 27.54
010056....................... 01.3970 17.99 010155.......... 00.9996 09.42 030068......... 00.9514 14.04 040063......... 01.4673 15.67 050056......... 01.3374 25.23
010058....................... 01.0881 12.96 020001.......... 01.4712 25.53 030069......... 01.3354 19.11 040064......... 01.0523 10.49 050057......... 01.4835 20.22
010059....................... 01.0165 14.17 020002.......... 01.0281 24.16 030071......... 00.9488 ....... 040066......... 01.1537 14.63 050058......... 01.4664 22.78
010061....................... 01.0127 14.70 020004.......... 01.1028 25.46 030072......... 00.9090 ....... 040067......... 01.0801 11.34 050060......... 01.5897 24.25
010062....................... 01.0042 13.45 020005.......... 00.9029 28.36 030073......... 00.9752 ....... 040069......... 01.1090 14.90 050061......... 01.4258 22.12
010064....................... 01.7890 17.85 020006.......... 01.1418 23.19 030074......... 00.8587 ....... 040070......... 00.9433 14.98 050063......... 01.4029 21.44
010065....................... 01.3668 14.30 020007.......... 00.8909 21.82 030075......... 00.8660 ....... 040071......... 01.5932 15.42 050065......... 01.6064 22.37
010066....................... 00.9789 10.87 020008.......... 01.1006 26.45 030076......... 00.9802 ....... 040072......... 01.0871 13.40 050066......... 01.2689 24.33
010068....................... 01.2370 18.82 020009.......... 00.9255 21.29 030077......... 00.8761 ....... 040074......... 01.2566 14.51 050067......... 01.3777 21.09
010069....................... 01.1589 13.06 020010.......... 00.9141 22.13 030078......... 01.1027 ....... 040075......... 01.0668 11.57 050068......... 01.0839 19.05
010072....................... 01.2161 12.72 020011.......... 01.0488 22.27 030079......... 00.7787 ....... 040076......... 01.0273 14.71 050069......... 01.6183 23.15
010073....................... 00.9701 09.66 020012.......... 01.3062 23.99 030080......... 01.6564 20.82 040077......... 00.9196 10.72 050070......... 01.2901 30.80
010078....................... 01.1795 15.04 020013.......... 01.0055 24.03 030083......... 01.3106 21.70 040078......... 01.4945 17.29 050071......... 01.3159 30.70
010079....................... 01.2807 12.53 020014.......... 01.0769 24.52 030084......... 00.9358 ....... 040080......... 01.0752 15.45 050072......... 01.3053 31.00
010080....................... 01.0389 12.99 020017.......... 01.5181 26.83 030085......... 01.5045 20.21 040081......... 00.9285 09.91 050073......... 01.3239 31.41
010081....................... 01.9832 16.16 020018.......... 00.8963 ....... 030086......... 01.3209 18.76 040082......... 01.2156 13.69 050074......... 01.2314 32.96
010083....................... 01.0377 13.25 020019.......... 00.8718 ....... 030087......... 01.6153 18.77 040084......... 01.0963 14.83 050075......... 01.4037 30.72
010084....................... 01.4816 16.61 020020.......... 00.8398 ....... 030088......... 01.3513 19.90 040085......... 01.2493 15.18 050076......... 01.7756 29.65
010085....................... 01.3233 17.11 020021.......... 00.8478 ....... 030089......... 01.5736 18.66 040088......... 01.3091 13.73 050077......... 01.6152 22.83
010086....................... 01.0507 13.54 020024.......... 01.0693 22.64 030092......... 01.5590 20.62 040090......... 00.8983 13.78 050078......... 01.3591 24.44
010087....................... 01.6243 16.88 020025.......... 01.0046 24.44 030093......... 01.3791 18.08 040091......... 01.2930 18.25 050079......... 01.5938 28.30
010089....................... 01.1934 14.91 020026.......... 01.3340 ....... 030094......... 01.2494 18.57 040093......... 00.9598 10.98 050080......... 01.2183 22.05
010090....................... 01.5725 16.40 020027.......... 00.9975 ....... 030095......... 01.2183 13.09 040095......... 00.9069 10.56 050081......... 01.6564 24.01
010091....................... 00.9195 13.43 030001.......... 01.3076 19.28 040001......... 01.1308 12.37 040100......... 01.2465 12.81 050082......... 01.4989 21.34
010092....................... 01.4209 15.17 030002.......... 01.7918 20.25 040002......... 01.1644 13.07 040105......... 01.0068 11.90 050084......... 01.5611 22.33
010094....................... 01.1410 16.76 030003.......... 01.8923 21.05 040003......... 01.0704 13.19 040106......... 01.2448 12.84 050088......... 01.1538 21.94
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Page 2 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050089....................... 01.3485 19.92 050189.......... 00.9777 21.50 050296......... 01.2071 22.69 050420......... 01.4424 25.15 050545......... 00.8420 20.39
050090....................... 01.2755 21.75 050191.......... 01.5032 20.64 050298......... 01.3081 20.18 050421......... 01.4112 24.62 050546......... 00.7212 21.10
050091....................... 01.1984 24.42 050192.......... 01.1071 18.74 050299......... 01.3607 22.49 050423......... 00.9821 19.25 050547......... 00.9602 20.65
050092....................... 00.8504 16.19 050193.......... 01.3631 22.56 050300......... 01.3100 18.87 050424......... 01.8316 22.16 050549......... 01.7182 25.86
050093....................... 01.5917 22.35 050194.......... 01.2409 25.03 050301......... 01.3825 21.54 050425......... 01.2719 30.41 050550......... 02.3168 23.34
050096....................... 01.1244 12.95 050195.......... 01.5876 31.29 050302......... 01.4049 24.31 050426......... 01.3055 23.89 050551......... 01.3473 24.20
050097....................... 01.5025 18.40 050196.......... 01.4205 16.40 050305......... 01.5824 29.82 050430......... 00.9919 15.94 050552......... 01.1633 22.44
050099....................... 01.4660 22.91 050197.......... 01.8278 29.07 050307......... 01.4439 20.51 050431......... 01.0836 22.58 050557......... 01.4928 21.08
050100....................... 01.6910 29.38 050199.......... 00.8980 19.48 050308......... 01.5797 29.77 050432......... 01.5774 23.69 050559......... 01.3672 24.18
050101....................... 01.3999 25.12 050204.......... 01.4910 23.12 050309......... 01.3306 23.63 050433......... 01.0327 17.37 050560......... 01.1894 ......
050102....................... 01.4714 22.34 050205.......... 01.3876 19.99 050310......... 01.2239 22.24 050434......... 01.1491 18.08 050561......... 01.2110 30.34
050103....................... 01.6097 26.74 050207.......... 01.2860 20.58 050312......... 01.9820 23.66 050435......... 01.2411 18.98 050564......... 01.2109 24.02
050104....................... 01.3906 21.73 050208.......... 00.9572 27.63 050313......... 01.1891 20.90 050436......... 01.0099 15.77 050565......... 01.1456 21.26
050107....................... 01.4355 22.92 050211.......... 01.3142 29.60 050315......... 01.1826 20.75 050438......... 01.6261 23.33 050566......... 00.8791 19.75
050108....................... 01.5819 22.78 050213.......... 01.3924 21.12 050317......... 01.3583 20.90 050440......... 01.4107 19.93 050567......... 01.6543 23.01
050109....................... 02.3436 24.68 050214.......... 01.4409 21.76 050320......... 01.3185 27.27 050441......... 01.9214 28.10 050568......... 01.4314 18.28
050110....................... 01.2436 18.72 050215.......... 01.5216 27.75 050324......... 01.8339 25.93 050443......... 00.9533 15.95 050569......... 01.3545 22.93
050111....................... 01.3786 18.81 050217.......... 01.3730 18.44 050325......... 01.2554 20.87 050444......... 01.3479 22.19 050570......... 01.7026 24.91
050112....................... 01.5234 22.15 050219.......... 01.3115 20.37 050327......... 01.5839 21.00 050446......... 00.8936 17.25 050571......... 01.4016 22.37
050113....................... 01.2749 28.23 050222.......... 01.5916 24.56 050328......... 01.4584 32.92 050447......... 01.0883 18.59 050573......... 01.6412 23.66
050114....................... 01.3978 21.65 050224.......... 01.5471 22.17 050329......... 01.3142 20.34 050448......... 01.1113 19.82 050575......... 01.2303 ......
050115....................... 01.6146 21.11 050225.......... 01.3284 20.67 050331......... 01.4090 27.22 050449......... 01.3527 21.99 050577......... 01.3652 20.32
050116....................... 01.4542 22.73 050226.......... 01.3349 22.58 050333......... 00.9767 18.66 050454......... 01.8309 26.10 050578......... 01.1731 23.70
050117....................... 01.2871 20.93 050228.......... 01.3665 29.90 050334......... 01.7683 28.22 050455......... 01.9292 22.89 050579......... 01.5656 26.94
050118....................... 01.2840 23.24 050230.......... 01.2972 26.22 050335......... 01.2505 19.62 050456......... 01.1314 20.24 050580......... 01.3595 23.47
050121....................... 01.4060 19.96 050231.......... 01.6364 24.14 050336......... 01.3398 21.04 050457......... 01.9435 28.66 050581......... 01.4162 24.63
050122....................... 01.7066 22.90 050232.......... 01.7628 24.17 050337......... 01.1726 23.87 050459......... 01.1929 28.20 050583......... 01.5880 23.08
050124....................... 01.2730 19.72 050233.......... 01.2974 30.88 050342......... 01.3686 17.55 050464......... 01.8776 22.62 050584......... 01.2006 22.39
050125....................... 01.3140 25.98 050234.......... 01.3251 22.00 050343......... 01.0325 18.56 050468......... 01.4046 16.26 050585......... 01.2357 23.70
050126....................... 01.4704 23.23 050235.......... 01.5105 25.00 050348......... 01.6030 22.83 050469......... 01.0879 17.33 050586......... 01.3647 21.76
050127....................... 01.2952 22.89 050236.......... 01.6626 24.28 050349......... 00.8988 14.28 050470......... 01.1148 21.29 050588......... 01.3703 26.55
050128....................... 01.5405 20.97 050238.......... 01.4959 22.95 050350......... 01.3856 22.68 050471......... 01.7202 24.07 050589......... 01.3124 25.37
050129....................... 01.5583 22.11 050239.......... 01.5085 21.24 050351......... 01.4774 24.81 050476......... 01.3437 19.12 050590......... 01.4086 23.00
050131....................... 01.2652 27.83 050240.......... 01.3951 22.82 050352......... 01.2941 23.35 050477......... 01.5136 24.50 050591......... 01.2861 27.01
050132....................... 01.4397 24.55 050241.......... 01.2374 25.78 050353......... 01.5622 21.45 050478......... 00.9225 21.73 050592......... 01.3408 20.34
050133....................... 01.3513 20.16 050242.......... 01.4698 27.10 050355......... 00.9696 15.53 050481......... 01.4166 24.85 050593......... 01.5583 24.40
050135....................... 01.3794 26.86 050243.......... 01.5323 21.58 050357......... 01.7247 23.17 050482......... 00.9451 14.55 050594......... 02.0151 23.81
050136....................... 01.3772 22.75 050245.......... 01.3837 21.74 050359......... 01.2172 18.78 050483......... 01.1666 23.89 050597......... 01.2786 21.91
050137....................... 01.3802 31.46 050248.......... 01.2124 24.50 050360......... 01.4656 30.15 050485......... 01.6275 22.34 050598......... 01.3940 26.87
050138....................... 01.8728 32.07 050251.......... 01.0753 17.68 050366......... 01.3174 20.47 050486......... 01.4180 24.94 050599......... 01.6829 22.70
050139....................... 01.3396 31.14 050253.......... 00.7232 18.87 050367......... 01.2881 27.02 050488......... 01.3879 30.41 050601......... 01.3075 29.03
050140....................... 01.4139 30.76 050254.......... 01.1940 22.13 050369......... 01.3323 23.30 050489......... 00.9718 27.10 050603......... 01.4252 23.50
050144....................... 01.5835 26.03 050256.......... 01.7700 19.70 050373......... 01.3964 23.83 050491......... 01.2797 23.76 050604......... 01.5933 29.56
050145....................... 01.3571 27.67 050257.......... 01.0715 20.65 050376......... 01.3932 25.86 050492......... 01.2458 23.05 050607......... 01.3006 21.79
050146....................... 01.3245 ....... 050260.......... 01.0965 21.96 050377......... 00.9012 15.01 050494......... 01.1674 24.95 050608......... 01.3067 15.23
050147....................... 00.6896 20.55 050261.......... 01.1927 17.91 050378......... 01.0814 22.45 050496......... 01.7959 31.60 050609......... 01.4365 31.39
050148....................... 01.1273 19.62 050262.......... 01.9179 26.89 050379......... 01.0921 19.04 050497......... 00.7948 ....... 050613......... 01.1496 22.70
050149....................... 01.4339 19.87 050263.......... 01.2879 24.24 050380......... 01.6703 28.31 050498......... 01.2636 22.42 050615......... 01.6939 23.31
050150....................... 01.2565 23.23 050264.......... 01.3732 26.01 050382......... 01.4511 20.97 050502......... 01.6551 23.61 050616......... 01.2953 20.68
050152....................... 01.4301 24.60 050267.......... 01.5239 24.88 050385......... 01.3960 24.83 050503......... 01.2916 23.01 050618......... 01.0619 19.36
050153....................... 01.6384 30.53 050270.......... 01.2432 23.60 050388......... 00.9028 14.19 050506......... 01.4122 25.57 050623......... 01.1349 24.40
050155....................... 01.1043 23.60 050272.......... 01.3296 19.69 050390......... 01.2211 20.80 050510......... 01.3632 30.59 050624......... 01.3670 25.95
050158....................... 01.6805 27.88 050274.......... 00.9624 18.36 050391......... 01.2785 21.61 050512......... 01.4686 31.38 050625......... 01.6096 24.00
050159....................... 01.2651 22.01 050276.......... 01.2223 26.99 050392......... 00.9426 17.56 050515......... 01.3589 30.78 050630......... 01.3621 21.26
050167....................... 01.4551 21.67 050277.......... 01.3817 21.30 050393......... 01.4157 21.56 050516......... 01.6670 24.33 050633......... 01.2959 21.76
050168....................... 01.6003 24.83 050278.......... 01.5174 23.01 050394......... 01.5428 20.71 050517......... 01.2879 19.15 050635......... 01.4145 31.17
050169....................... 01.5891 24.53 050279.......... 01.2461 20.58 050396......... 01.6157 21.89 050522......... 01.3128 30.40 050636......... 01.4311 20.28
050170....................... 01.5175 21.58 050280.......... 01.6551 22.80 050397......... 01.0118 19.97 050523......... 01.2703 27.65 050638......... 01.1002 24.28
050172....................... 01.2609 19.96 050281.......... 01.4519 22.74 050401......... 01.1174 19.09 050526......... 01.3687 24.28 050641......... 01.2473 12.26
050173....................... 01.2203 23.70 050282.......... 01.3433 21.42 050404......... 01.1443 16.51 050528......... 01.3542 16.46 050643......... 00.7832 ......
050174....................... 01.6873 27.89 050283.......... 01.1267 27.59 050406......... 01.1263 15.29 050531......... 01.3012 23.60 050644......... 00.9053 26.86
050175....................... 01.3926 21.97 050286.......... 01.0350 17.99 050407......... 01.3254 27.06 050534......... 01.3853 23.83 050660......... 01.3428 ......
050177....................... 01.2994 18.76 050289.......... 01.7845 27.38 050410......... 01.0706 17.45 050535......... 01.3827 22.46 050661......... 00.8831 20.21
050179....................... 01.2600 17.29 050290.......... 01.6330 32.31 050411......... 01.4042 29.35 050537......... 01.2622 21.30 050662......... 00.8549 21.17
050180....................... 01.5539 30.12 050291.......... 01.2553 24.46 050414......... 01.2846 24.32 050539......... 01.2184 21.90 050663......... 01.0604 23.51
050183....................... 01.1940 19.09 050292.......... 01.0963 21.20 050417......... 01.3037 19.65 050541......... 01.5870 31.06 050666......... 00.7423 23.76
050186....................... 01.2694 24.12 050293.......... 01.1312 19.93 050418......... 01.4191 24.24 050542......... 01.2270 13.79 050667......... 01.0672 24.88
050188....................... 01.3467 25.25 050295.......... 01.4144 20.86 050419......... 01.3136 18.88 050543......... 00.9214 21.68 050668......... 01.1532 28.20
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[[Page 27507]]
Page 3 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050670....................... 00.7582 20.12 060046.......... 01.1205 16.56 080005......... 01.3363 16.82 100071......... 01.3024 16.98 100167......... 01.3944 20.55
050672....................... 00.6267 23.77 060047.......... 00.9606 11.40 080006......... 01.3822 20.49 100072......... 01.2515 17.24 100168......... 01.3799 19.35
050674....................... 01.2111 29.18 060049.......... 01.3511 17.47 080007......... 01.3620 17.99 100073......... 01.7938 20.61 100169......... 01.8590 18.29
050675....................... 01.7056 16.32 060050.......... 01.1719 14.62 090001......... 01.4216 19.65 100075......... 01.6403 17.85 100170......... 01.4917 16.50
050676....................... 00.9864 13.83 060052.......... 01.0999 18.38 090002......... 01.3022 20.51 100076......... 01.3869 17.15 100172......... 01.3694 13.38
050677....................... 01.4253 32.99 060053.......... 00.9988 13.73 090003......... 01.3041 24.74 100077......... 01.3153 16.78 100173......... 01.6691 16.33
050678....................... 01.0713 24.07 060054.......... 01.3361 16.74 090004......... 01.7168 23.49 100078......... 01.1683 15.14 100174......... 01.5295 18.20
050680....................... 01.2114 26.13 060056.......... 00.9577 13.37 090005......... 01.3431 27.07 100079......... 01.7501 16.01 100175......... 01.2130 16.18
050682....................... 00.8558 14.98 060057.......... 01.0356 21.11 090006......... 01.3749 19.52 100080......... 01.6306 19.40 100176......... 02.0431 21.95
050684....................... 01.2074 21.30 060058.......... 00.9237 12.54 090007......... 01.3832 19.58 100081......... 01.1202 13.33 100177......... 01.3403 18.55
050685....................... 01.2219 26.94 060060.......... 00.9651 12.21 090008......... 01.5276 24.06 100082......... 01.5459 17.93 100179......... 01.6520 19.03
050686....................... 01.3503 30.96 060062.......... 00.9518 15.85 090010......... 01.0013 21.70 100083......... 01.3240 17.30 100180......... 01.4188 17.49
050688....................... 01.2730 27.89 060063.......... 01.0264 11.12 090011......... 01.9804 24.77 100084......... 01.5314 16.53 100181......... 01.2846 17.59
050689....................... 01.3988 29.12 060064.......... 01.4325 20.21 090015......... 01.3306 ....... 100085......... 01.4349 19.50 100183......... 01.3710 19.18
050690....................... 01.4363 30.39 060065.......... 01.3463 19.98 100001......... 01.5247 18.83 100086......... 01.3328 21.32 100186......... 01.4758 16.70
050693....................... 01.9152 28.80 060066.......... 00.9950 13.10 100002......... 01.4789 19.71 100087......... 01.8071 20.71 100187......... 01.4501 18.35
050694....................... 01.3678 21.20 060068.......... 01.2760 14.00 100004......... 01.0274 11.81 100088......... 01.6730 17.32 100189......... 01.3707 23.13
050695....................... 01.1808 24.30 060070.......... 01.0357 14.99 100005......... 01.0178 16.26 100090......... 01.4256 16.07 100191......... 01.3315 19.19
050696....................... 02.0076 27.85 060071.......... 01.2259 14.69 100006......... 01.5531 18.99 100092......... 01.4411 16.20 100199......... 01.4473 21.29
050697....................... 01.1093 17.93 060073.......... 01.0017 14.32 100007......... 01.8477 19.61 100093......... 01.5156 14.28 100200......... 01.3972 21.35
050698....................... 01.1189 22.83 060075.......... 01.3472 20.27 100008......... 01.7361 19.80 100098......... 01.1482 17.43 100203......... 01.2603 19.34
050699....................... 00.5855 23.13 060076.......... 01.3675 15.97 100009......... 01.5641 17.89 100099......... 01.2518 13.09 100204......... 01.6232 19.95
050700....................... 01.4412 32.46 060085.......... 00.9819 10.94 100010......... 01.5475 20.58 100102......... 01.1033 16.44 100206......... 01.3458 19.47
050701....................... 01.3170 27.13 060087.......... 01.6558 18.67 100012......... 01.6776 16.91 100103......... 01.1730 14.46 100207......... 01.4710 19.86
050702....................... 00.8637 16.98 060088.......... 01.0388 15.38 100014......... 01.4272 18.57 100105......... 01.4697 18.08 100208......... 01.6409 21.14
050704....................... 01.2140 20.48 060090.......... 00.9518 14.23 100015......... 01.2444 17.60 100106......... 01.0395 15.46 100209......... 01.6671 ......
050706....................... 00.9234 16.16 060096.......... 00.9724 21.69 100017......... 01.6489 17.18 100107......... 01.4676 18.26 100210......... 01.6647 16.51
050707....................... 01.2237 25.62 060100.......... 01.4045 20.95 100018......... 01.2869 19.94 100108......... 01.1017 15.45 100211......... 01.3441 19.17
050708....................... 00.9493 15.13 060103.......... 01.2269 21.10 100019......... 01.4930 18.81 100109......... 01.3522 16.81 100212......... 01.6646 18.54
050709....................... 01.3030 ....... 060104.......... 01.3213 20.32 100020......... 01.3365 18.31 100110......... 01.4128 18.91 100213......... 01.5438 20.00
050710....................... 01.4014 ....... 070001.......... 01.7582 24.78 100022......... 01.8009 23.05 100112......... 00.9738 10.84 100217......... 01.3055 17.06
050711....................... 02.3868 ....... 070002.......... 01.8728 24.78 100023......... 01.3489 15.88 100113......... 02.0848 18.19 100220......... 01.9563 19.66
050712....................... 02.1147 ....... 070003.......... 01.1239 24.50 100024......... 01.3583 19.54 100114......... 01.4930 17.73 100221......... 01.5644 20.68
060001....................... 01.5550 18.95 070004.......... 01.1696 23.70 100025......... 01.8825 16.22 100117......... 01.3334 18.18 100222......... 01.3723 18.80
060003....................... 01.2961 15.85 070005.......... 01.3792 25.45 100026......... 01.6477 15.52 100118......... 01.2737 16.03 100223......... 01.4892 18.53
060004....................... 01.2624 19.46 070006.......... 01.3529 26.73 100027......... 00.9736 11.53 100121......... 01.3068 15.44 100224......... 01.4648 19.77
060006....................... 01.1955 16.19 070007.......... 01.3475 24.08 100028......... 01.2678 16.38 100122......... 01.4565 16.39 100225......... 01.3368 19.52
060007....................... 01.1900 13.06 070008.......... 01.3124 23.47 100029......... 01.4029 18.94 100124......... 01.3643 19.41 100226......... 01.3383 16.58
060008....................... 01.0198 14.31 070009.......... 01.2830 25.01 100030......... 01.2690 18.25 100125......... 01.1630 17.77 100228......... 01.2947 21.09
060009....................... 01.4621 19.88 070010.......... 01.5535 22.46 100032......... 01.9188 17.39 100126......... 01.4954 18.74 100229......... 01.3211 16.27
060010....................... 01.5276 21.10 070011.......... 01.3259 22.80 100034......... 01.7338 18.34 100127......... 01.6870 17.42 100230......... 01.5471 18.97
060011....................... 01.3023 20.75 070012.......... 01.2576 23.38 100035......... 01.6138 16.46 100128......... 02.2417 20.13 100231......... 01.6613 17.46
060012....................... 01.3852 15.79 070013.......... 01.2822 24.01 100038......... 01.5951 21.18 100129......... 01.2509 17.45 100232......... 01.2675 17.64
060013....................... 01.2654 18.83 070015.......... 01.3569 23.82 100039......... 01.7158 21.15 100130......... 01.2008 17.45 100234......... 01.5324 19.03
060014....................... 01.6915 20.52 070016.......... 01.3194 25.46 100040......... 01.6731 16.31 100131......... 01.3922 18.44 100235......... 01.4827 17.51
060015....................... 01.5657 19.33 070017.......... 01.3781 23.54 100043......... 01.4570 17.78 100132......... 01.4189 15.67 100236......... 01.4442 13.79
060016....................... 01.0954 11.42 070018.......... 01.3719 27.83 100044......... 01.5045 19.01 100134......... 01.0741 14.50 100237......... 02.1446 22.65
060018....................... 01.2199 16.36 070019.......... 01.2169 24.04 100045......... 01.4032 17.12 100135......... 01.5224 16.11 100238......... 01.4858 18.68
060020....................... 01.5176 16.73 070020.......... 01.3709 24.32 100046......... 01.5110 18.53 100137......... 01.3279 18.42 100239......... 01.4622 19.34
060022....................... 01.6695 17.89 070021.......... 01.2987 25.47 100047......... 01.9163 18.62 100138......... 00.9478 13.00 100240......... 00.8437 15.06
060023....................... 01.6463 16.65 070022.......... 01.7641 24.30 100048......... 01.0025 11.69 100139......... 01.0496 14.54 100241......... 00.9433 12.47
060024....................... 01.8181 22.01 070024.......... 01.3541 23.81 100049......... 01.3263 18.03 100140......... 01.2518 16.87 100242......... 01.4135 16.29
060026....................... 01.4223 19.44 070025.......... 01.7842 24.06 100050......... 01.2227 15.06 100142......... 01.2004 16.68 100243......... 01.4119 18.82
060027....................... 01.6577 19.01 070026.......... 01.2223 23.07 100051......... 01.1532 16.60 100144......... 01.1466 13.65 100244......... 01.4339 17.32
060028....................... 01.4947 21.29 070027.......... 01.2599 24.31 100052......... 01.3772 15.60 100145......... 01.3481 14.87 100246......... 01.3465 20.92
060029....................... 00.9485 13.93 070028.......... 01.4783 24.67 100053......... 01.2886 17.36 100146......... 01.2770 14.27 100248......... 01.6989 17.88
060030....................... 01.3165 20.36 070029.......... 01.3524 21.65 100054......... 01.2923 17.44 100147......... 01.0996 13.43 100249......... 01.3543 18.87
060031....................... 01.6115 18.95 070030.......... 01.2990 24.71 100055......... 01.3679 17.47 100150......... 01.3759 18.64 100252......... 01.2419 19.21
060032....................... 01.5777 19.35 070031.......... 01.2706 22.24 100056......... 01.4655 19.83 100151......... 01.8572 18.63 100253......... 01.4755 20.60
060033....................... 01.1561 11.96 070033.......... 01.2881 28.25 100057......... 01.3455 16.78 100154......... 01.5689 17.95 100254......... 01.5854 17.50
060034....................... 01.4958 16.90 070034.......... 01.3752 24.74 100060......... 01.8491 17.71 100156......... 01.2204 18.65 100255......... 01.3322 19.00
060036....................... 01.1712 14.37 070035.......... 01.3469 24.31 100061......... 01.5100 20.88 100157......... 01.6134 19.31 100256......... 01.8955 19.32
060037....................... 01.0382 13.22 070036.......... 01.4320 26.98 100062......... 01.7185 16.94 100159......... 00.9856 12.76 100258......... 01.6509 21.12
060038....................... 01.0192 12.25 070039.......... 00.9213 ....... 100063......... 01.3423 16.12 100160......... 01.1059 18.07 100259......... 01.4493 16.36
060041....................... 00.9203 16.53 080001.......... 01.6101 23.66 100067......... 01.4267 16.38 100161......... 01.5194 19.76 100260......... 01.4016 20.44
060042....................... 01.0532 18.49 080002.......... 01.1904 17.32 100068......... 01.3880 17.42 100162......... 01.3924 14.53 100262......... 01.4109 19.32
060043....................... 00.9506 11.78 080003.......... 01.3137 19.32 100069......... 01.3653 17.29 100165......... 01.2958 13.45 100263......... 01.3896 15.44
060044....................... 01.2631 17.32 080004.......... 01.2871 17.59 100070......... 01.4420 17.56 100166......... 01.4618 20.31 100264......... 01.3958 18.24
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
100265....................... 01.3686 17.47 110063.......... 01.0768 11.44 110156......... 01.0003 12.68 130011......... 01.2386 16.74 140045......... 01.0555 14.21
100266....................... 01.2337 15.64 110064.......... 01.2883 15.87 110161......... 01.3328 20.79 130012......... 01.0233 18.53 140046......... 01.3023 14.83
100267....................... 01.3092 16.39 110065.......... 01.0143 12.00 110162......... 00.8588 ....... 130013......... 01.2416 17.21 140047......... 01.1406 13.20
100268....................... 01.1990 22.00 110066.......... 01.4374 16.30 110163......... 01.4549 18.52 130014......... 01.3094 16.43 140048......... 01.2744 21.50
100269....................... 01.3605 19.07 110069.......... 01.1706 15.22 110164......... 01.4190 19.63 130015......... 00.8608 12.43 140049......... 01.5796 19.35
100270....................... 00.8185 12.95 110070.......... 01.1733 11.37 110165......... 01.3107 17.47 130016......... 00.9300 16.18 140051......... 01.4912 19.14
100271....................... 01.6614 19.27 110071.......... 01.0308 10.29 110166......... 01.4995 16.67 130017......... 01.3710 13.03 140052......... 01.3150 16.77
100273....................... 00.5356 19.72 110072.......... 01.0243 11.53 110168......... 01.6538 19.22 130018......... 01.7015 17.60 140053......... 01.8914 17.88
100275....................... 01.4206 21.96 110073.......... 01.2050 12.67 110169......... 00.7308 19.70 130019......... 01.1172 13.74 140054......... 01.3616 26.25
100276....................... 01.3027 21.94 110074.......... 01.4803 18.11 110171......... 01.4451 21.21 130021......... 01.0324 11.96 140055......... 00.9382 13.00
100277....................... 01.0093 12.71 110075.......... 01.2149 15.29 110172......... 01.3290 22.83 130022......... 01.1917 15.44 140058......... 01.2318 15.26
100279....................... 01.3786 18.35 110076.......... 01.3902 18.01 110174......... 01.0473 17.57 130024......... 01.0580 15.25 140059......... 01.1334 13.52
100280....................... 01.3831 16.93 110078.......... 01.6637 20.46 110176......... 01.1251 19.42 130025......... 01.1537 15.21 140061......... 01.0878 13.80
100281....................... 01.2517 20.85 110079.......... 01.3869 21.08 110177......... 01.4857 19.21 130026......... 01.1747 17.89 140062......... 01.2451 23.10
100282....................... 01.0482 16.99 110080.......... 01.1544 16.86 110178......... 01.3702 16.78 130027......... 00.9528 17.18 140063......... 01.3960 22.48
100283....................... 01.5478 ....... 110082.......... 02.0163 20.36 110179......... 01.2381 21.56 130028......... 01.2515 16.08 140064......... 01.2951 16.15
110001....................... 01.2914 17.40 110083.......... 01.7255 20.66 110181......... 00.9860 12.59 130029......... 01.0268 17.07 140065......... 01.4926 23.68
110002....................... 01.2397 14.83 110086.......... 01.2253 13.74 110183......... 01.3704 19.70 130030......... 01.0243 16.20 140066......... 01.3711 13.39
110003....................... 01.3129 15.41 110087.......... 01.3386 19.17 110184......... 01.1715 17.58 130031......... 01.0201 13.26 140067......... 01.8194 18.24
110004....................... 01.3118 16.17 110088.......... 00.9740 11.17 110185......... 01.0833 12.23 130034......... 01.0393 16.38 140068......... 01.3583 19.00
110005....................... 01.1872 21.40 110089.......... 01.2146 15.37 110186......... 01.3060 15.97 130035......... 01.0736 15.37 140069......... 01.0029 14.23
110006....................... 01.3597 18.00 110091.......... 01.3449 19.15 110187......... 01.2469 17.19 130036......... 01.2609 12.50 140070......... 01.2830 16.18
110007....................... 01.4425 15.69 110092.......... 01.1821 12.55 110188......... 01.4186 18.00 130037......... 01.2616 14.58 140074......... 00.9704 14.60
110008....................... 01.2405 15.47 110093.......... 01.0096 09.81 110189......... 01.1327 19.78 130043......... 00.9469 14.61 140075......... 01.4685 21.53
110009....................... 01.0377 15.71 110094.......... 00.9542 12.06 110190......... 01.0859 14.41 130044......... 01.1660 12.37 140077......... 01.1503 17.05
110010....................... 02.1503 21.39 110095.......... 01.2750 13.86 110191......... 01.3482 18.06 130045......... 01.0284 12.15 140079......... 01.2410 20.90
110011....................... 01.2868 16.01 110096.......... 01.1414 14.30 110192......... 01.3977 22.17 130048......... 01.0663 11.90 140080......... 01.5779 19.60
110013....................... 01.1312 14.36 110097.......... 01.0166 15.58 110193......... 01.2300 16.16 130049......... 01.2960 17.55 140081......... 01.0821 13.92
110014....................... 01.0340 14.48 110098.......... 01.0881 11.76 110194......... 00.9644 11.77 130054......... 00.9683 17.12 140082......... 01.5059 22.10
110015....................... 01.3622 16.52 110100.......... 01.0968 12.27 110195......... 01.0844 10.50 130056......... 00.8652 09.45 140083......... 01.2600 16.51
110016....................... 01.2991 14.21 110101.......... 01.1035 09.24 110198......... 01.3316 22.58 130058......... 01.0150 12.87 140084......... 01.2248 17.94
110017....................... 00.8897 11.01 110103.......... 00.9630 10.35 110200......... 01.9437 15.79 130060......... 01.1458 18.38 140086......... 01.1464 13.93
110018....................... 01.1357 17.20 110104.......... 01.1073 13.28 110201......... 01.4531 16.13 130061......... 00.9513 ....... 140087......... 01.3852 17.10
110020....................... 01.2352 17.30 110105.......... 01.1304 15.17 110203......... 00.9692 14.94 140001......... 01.2958 14.63 140088......... 01.6480 23.33
110023....................... 01.2361 17.53 110107.......... 01.8146 17.59 110204......... 00.7960 13.48 140002......... 01.2776 17.04 140089......... 01.2253 15.85
110024....................... 01.4802 18.74 110108.......... 00.9720 11.27 110205......... 01.1080 11.84 140003......... 01.0184 13.14 140090......... 01.5101 23.62
110025....................... 01.4157 16.85 110109.......... 01.1115 12.14 110207......... 01.1008 15.59 140004......... 01.0799 13.75 140091......... 01.8655 17.70
110026....................... 01.1891 13.87 110111.......... 01.1934 14.70 110208......... 00.9734 14.94 140005......... 00.9511 09.98 140093......... 01.1961 17.17
110027....................... 01.1013 14.56 110112.......... 01.1522 15.06 110209......... 00.8222 ....... 140007......... 01.4675 20.56 140094......... 01.2905 18.81
110028....................... 01.5984 17.75 110113.......... 01.1384 12.86 120001......... 01.7331 24.22 140008......... 01.4859 20.57 140095......... 01.3991 ......
110029....................... 01.3374 17.71 110114.......... 01.0749 13.75 120002......... 01.1971 21.46 140010......... 01.3888 22.14 140097......... 00.9102 14.15
110030....................... 01.2807 16.60 110115.......... 01.6188 21.82 120003......... 01.1450 21.82 140011......... 01.1465 15.31 140100......... 01.2229 17.62
110031....................... 01.3367 19.58 110118.......... 01.0422 13.18 120004......... 01.2653 20.56 140012......... 01.2840 17.59 140101......... 01.2108 18.04
110032....................... 01.2298 15.31 110120.......... 01.0800 13.35 120005......... 01.2656 18.34 140013......... 01.6579 16.49 140102......... 01.0422 14.09
110033....................... 01.5204 20.32 110121.......... 01.1802 11.84 120006......... 01.2116 22.75 140014......... 01.0745 16.31 140103......... 01.3357 16.66
110034....................... 01.5019 16.64 110122.......... 01.3550 16.03 120007......... 01.6278 20.27 140015......... 01.2937 13.45 140105......... 01.3085 18.25
110035....................... 01.3991 18.53 110124.......... 01.0703 15.32 120009......... 01.0061 18.05 140016......... 00.9317 11.59 140107......... 01.0869 11.63
110036....................... 01.6840 22.81 110125.......... 01.2217 15.97 120010......... 01.8369 22.11 140018......... 01.4564 18.85 140108......... 01.3663 20.00
110037....................... 01.0904 10.18 110127.......... 00.9066 14.43 120011......... 01.2382 30.31 140019......... 00.9926 11.80 140109......... 01.1410 12.95
110038....................... 01.4674 15.04 110128.......... 01.1920 17.54 120012......... 01.0209 20.30 140024......... 01.0178 13.59 140110......... 01.2359 14.51
110039....................... 01.3709 17.93 110129.......... 01.6749 13.01 120014......... 01.3556 21.25 140025......... 01.0795 15.88 140112......... 01.0953 13.55
110040....................... 01.0270 16.26 110130.......... 01.0721 10.57 120015......... 00.8375 21.01 140026......... 01.1409 15.58 140113......... 01.4647 19.21
110041....................... 01.2250 16.43 110132.......... 01.1433 12.87 120016......... 00.8558 21.94 140027......... 01.3182 15.96 140114......... 01.3202 18.95
110042....................... 01.2103 14.63 110134.......... 00.8944 11.65 120018......... 01.0071 21.16 140029......... 01.3782 19.62 140115......... 01.2339 19.32
110043....................... 01.7167 15.17 110135.......... 01.1981 13.83 120019......... 01.1834 19.48 140030......... 01.6711 21.46 140116......... 01.2862 19.68
110044....................... 01.0960 14.31 110136.......... 01.1213 13.57 120021......... 00.9888 19.68 140031......... 01.1749 13.02 140117......... 01.4895 17.63
110045....................... 01.2388 22.04 110140.......... 00.8182 15.03 120022......... 01.7240 17.83 140032......... 01.2531 16.44 140118......... 01.6767 22.66
110046....................... 01.1993 15.07 110141.......... 00.9067 11.65 120026......... 01.2802 22.30 140033......... 01.2640 19.10 140119......... 01.6872 19.58
110048....................... 01.3128 12.97 110142.......... 00.9806 11.15 120027......... 01.5395 21.16 140034......... 01.1800 16.74 140120......... 01.5073 14.72
110049....................... 01.0704 13.71 110143.......... 01.3994 20.07 130001......... 01.0424 17.21 140035......... 01.0305 10.70 140121......... 01.5215 10.91
110050....................... 01.0669 14.00 110144.......... 01.1678 16.44 130002......... 01.3774 14.66 140036......... 01.2388 15.03 140122......... 01.5566 21.02
110051....................... 00.9865 16.35 110146.......... 01.0299 09.43 130003......... 01.3112 18.11 140037......... 00.9794 12.24 140124......... 01.1139 23.06
110052....................... 00.9774 09.11 110149.......... 01.1319 12.17 130005......... 01.4396 18.19 140038......... 01.1510 15.00 140125......... 01.3450 15.60
110054....................... 01.2816 16.57 110150.......... 01.3658 16.56 130006......... 01.8983 18.19 140039......... 00.9224 11.51 140127......... 01.3522 16.83
110056....................... 00.9765 12.61 110152.......... 01.1295 13.06 130007......... 01.6434 18.60 140040......... 01.3093 14.34 140128......... 01.0595 16.10
110059....................... 01.2900 14.39 110153.......... 01.0212 15.33 130008......... 00.9857 10.28 140041......... 01.2320 15.01 140129......... 01.0555 13.18
110061....................... 01.0143 10.61 110154.......... 00.8337 12.68 130009......... 00.9627 14.78 140042......... 01.0524 13.30 140130......... 01.2738 21.67
110062....................... 00.9181 09.73 110155.......... 01.2376 12.27 130010......... 00.9403 15.04 140043......... 01.1790 16.37 140132......... 01.4146 18.58
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[[Page 27509]]
Page 5 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
140133....................... 01.3730 19.77 140230.......... 00.9439 15.48 150043......... 01.0625 16.58 150127......... 01.0419 14.34 160069......... 01.4042 16.05
140135....................... 01.3146 14.29 140231.......... 01.6272 19.79 150044......... 01.2634 17.63 150128......... 01.2340 18.59 160070......... 01.0255 13.84
140137....................... 01.0354 13.61 140233.......... 01.7471 16.57 150045......... 01.0913 15.00 150129......... 01.1915 20.35 160072......... 01.0688 12.08
140138....................... 00.9661 12.15 140234.......... 01.1838 15.82 150046......... 01.5896 16.06 150130......... 01.1496 15.90 160073......... 01.0070 11.50
140139....................... 01.0792 13.46 140236.......... 01.0311 12.82 150047......... 01.6212 17.74 150132......... 01.3365 19.17 160074......... 01.1069 12.89
140140....................... 01.1317 13.05 140239.......... 01.5856 18.81 150048......... 01.1679 16.18 150133......... 01.2095 14.96 160075......... 01.1112 13.84
140141....................... 00.8984 13.30 140240.......... 01.5048 20.90 150049......... 01.0776 13.72 150134......... 01.2828 16.61 160076......... 01.0692 16.28
140143....................... 01.0643 15.85 140242.......... 01.5726 22.51 150050......... 01.1998 14.50 150136......... 00.9472 18.69 160077......... 01.1216 10.97
140144....................... 00.9856 16.57 140245.......... 01.1273 13.55 150051......... 01.3841 16.82 150138......... 01.1623 ....... 160079......... 01.4245 15.22
140145....................... 01.2030 14.31 140246.......... 01.0570 12.03 150052......... 01.0743 12.93 150139......... 01.4806 ....... 160080......... 01.2082 15.41
140146....................... 00.9666 14.85 140250.......... 01.3165 21.35 150053......... 01.0618 16.69 150141......... 01.0859 ....... 160081......... 01.0672 14.36
140147....................... 01.1866 13.37 140251.......... 01.3066 18.25 150054......... 01.1376 12.39 150142......... 02.4300 ....... 160082......... 01.7545 17.09
140148....................... 01.8018 16.51 140252.......... 01.4201 21.25 150056......... 01.6228 21.59 150897......... 04.9892 ....... 160083......... 01.5789 17.49
140150....................... 01.5561 26.00 140253.......... 01.4456 ....... 150057......... 02.3179 15.06 160001......... 01.2719 16.39 160085......... 01.0916 12.79
140151....................... 01.1119 17.61 140258.......... 01.5345 21.07 150058......... 01.6930 18.64 160002......... 01.1888 13.13 160086......... 01.0283 12.56
140152....................... 01.0750 22.48 140271.......... 01.0260 13.54 150059......... 01.3218 18.91 160003......... 01.0221 11.87 160088......... 01.0017 13.10
140155....................... 01.1854 16.91 140275.......... 01.2294 18.20 150060......... 01.1281 12.79 160005......... 01.1072 12.93 160089......... 01.1591 14.12
140158....................... 01.2597 21.41 140276.......... 01.9589 20.48 150061......... 01.2957 15.86 160007......... 01.0085 12.02 160090......... 01.0066 13.98
140160....................... 01.2326 15.34 140280.......... 01.2769 16.16 150062......... 01.0670 15.20 160008......... 01.1043 13.93 160091......... 01.0987 10.56
140161....................... 01.1373 17.05 140281.......... 01.6388 20.19 150063......... 01.0538 18.88 160009......... 01.1577 13.54 160092......... 00.9736 12.93
140162....................... 01.7778 18.38 140285.......... 01.2063 14.75 150064......... 01.2100 16.48 160012......... 01.0588 14.05 160093......... 01.1351 15.20
140164....................... 01.2855 16.01 140286.......... 01.1491 17.59 150065......... 01.1505 15.94 160013......... 01.2189 16.64 160094......... 01.2168 14.79
140165....................... 01.1085 13.06 140288.......... 01.7781 22.47 150066......... 01.0021 13.75 160014......... 01.0459 12.72 160095......... 01.0266 12.30
140166....................... 01.2889 16.62 140289.......... 01.3089 15.67 150067......... 01.1221 14.35 160016......... 01.2911 15.68 160097......... 01.0785 13.47
140167....................... 01.1636 14.64 140290.......... 01.3385 19.21 150069......... 01.2347 16.53 160018......... 00.9429 13.19 160098......... 01.0760 13.90
140168....................... 01.1840 15.02 140291.......... 01.2645 22.64 150070......... 01.0350 16.16 160020......... 01.0963 12.11 160099......... 00.9737 12.80
140170....................... 01.1280 12.39 140292.......... 01.1678 19.04 150071......... 01.1562 12.69 160021......... 01.0439 13.85 160101......... 01.1220 17.71
140171....................... 00.9149 12.53 140294.......... 01.1864 16.10 150072......... 01.1914 15.32 160023......... 01.1458 13.66 160102......... 01.3668 14.31
140172....................... 01.5065 18.29 140297.......... 01.2589 21.42 150073......... 01.0044 15.49 160024......... 01.5710 17.39 160103......... 01.0113 12.95
140173....................... 00.9721 13.11 140300.......... 01.6785 25.11 150074......... 01.5934 19.00 160026......... 01.0986 15.21 160104......... 01.2335 19.21
140174....................... 01.4333 18.89 150001.......... 01.0846 16.95 150075......... 01.2247 13.82 160027......... 01.1671 13.22 160106......... 01.0829 14.18
140176....................... 01.2617 18.83 150002.......... 01.4319 19.23 150076......... 01.1512 19.89 160028......... 01.3407 17.78 160107......... 01.1437 13.78
140177....................... 01.2945 16.44 150003.......... 01.7075 18.32 150077......... 01.2659 16.21 160029......... 01.4962 17.46 160108......... 01.1602 14.09
140179....................... 01.3297 19.51 150004.......... 01.4226 19.99 150078......... 01.0834 17.20 160030......... 01.2338 16.67 160109......... 01.1631 12.01
140180....................... 01.5189 20.22 150005.......... 01.1932 17.16 150079......... 01.1390 13.01 160031......... 01.1797 13.26 160110......... 01.4994 17.76
140181....................... 01.3046 18.82 150006.......... 01.2074 16.72 150082......... 01.4965 18.33 160032......... 01.1573 14.66 160111......... 01.1019 10.75
140182....................... 01.3248 19.11 150007.......... 01.2302 17.95 150084......... 01.8737 21.80 160033......... 01.7246 15.82 160112......... 01.4123 14.45
140184....................... 01.1967 14.20 150008.......... 01.3398 18.38 150086......... 01.3006 15.72 160034......... 01.0681 13.81 160113......... 00.9561 11.39
140185....................... 01.4505 16.35 150009.......... 01.3365 16.97 150088......... 01.1917 16.71 160035......... 00.9375 11.91 160114......... 01.0697 14.13
140186....................... 01.3274 18.01 150010.......... 01.2041 16.10 150089......... 01.3985 18.99 160036......... 01.0756 12.83 160115......... 01.0280 13.87
140187....................... 01.4861 16.33 150011.......... 01.2190 16.76 150090......... 01.2596 19.34 160037......... 01.1621 14.80 160116......... 01.1691 15.46
140188....................... 00.9575 10.54 150012.......... 01.6875 20.57 150091......... 01.0611 15.60 160039......... 01.0670 15.23 160117......... 01.3337 15.63
140189....................... 01.1712 15.74 150013.......... 01.1675 13.09 150092......... 01.0673 12.44 160040......... 01.3537 16.04 160118......... 01.0360 12.42
140190....................... 01.1195 13.36 150014.......... 01.4216 18.85 150094......... 01.0035 16.65 160041......... 01.0646 12.88 160120......... 01.0091 09.94
140191....................... 01.3775 23.16 150015.......... 01.2264 17.85 150095......... 01.1144 15.78 160043......... 01.0338 13.38 160122......... 01.1669 14.96
140192....................... 01.1869 16.51 150017.......... 01.8448 17.26 150096......... 01.0971 17.15 160044......... 01.1574 13.36 160123......... 01.1780 12.18
140193....................... 01.0112 12.24 150018.......... 01.2919 17.47 150097......... 01.1277 16.53 160045......... 01.6987 17.48 160124......... 01.2526 15.35
140197....................... 01.2709 16.05 150019.......... 01.1266 13.09 150098......... 01.1300 11.81 160046......... 01.0369 11.92 160126......... 01.1504 13.82
140199....................... 01.0139 15.13 150020.......... 01.1554 13.19 150099......... 01.3115 17.10 160047......... 01.3602 15.87 160129......... 01.0228 13.07
140200....................... 01.4295 20.12 150021.......... 01.6718 18.22 150100......... 01.6839 18.15 160048......... 01.0179 11.76 160130......... 01.1652 13.04
140202....................... 01.3141 20.09 150022.......... 01.1381 17.62 150101......... 01.0868 14.46 160049......... 00.9842 12.04 160131......... 01.1087 12.63
140203....................... 01.1570 19.02 150023.......... 01.4914 17.81 150102......... 01.0903 14.61 160050......... 01.0246 14.12 160134......... 00.9843 11.37
140205....................... 00.9221 13.88 150024.......... 01.4448 16.96 150103......... 01.0416 17.63 160051......... 00.9907 12.90 160135......... 01.0019 13.24
140206....................... 01.0864 19.58 150025.......... 01.4616 16.32 150104......... 01.1413 15.09 160052......... 01.0589 14.80 160138......... 01.0588 13.48
140207....................... 01.3743 26.85 150026.......... 01.1878 16.69 150105......... 01.4085 16.61 160054......... 01.0231 10.82 160140......... 01.0939 14.86
140208....................... 01.6111 23.73 150027.......... 01.0647 16.04 150106......... 01.1373 15.58 160055......... 01.0477 11.48 160142......... 01.0237 13.60
140209....................... 01.7011 17.46 150029.......... 01.2733 20.57 150109......... 01.4583 16.04 160056......... 01.0409 13.16 160143......... 01.1324 13.03
140210....................... 01.0690 12.87 150030.......... 01.1956 16.20 150110......... 00.9896 14.72 160057......... 01.3309 15.92 160145......... 01.0880 13.74
140211....................... 01.2233 20.44 150031.......... 01.0590 15.93 150111......... 01.2056 12.88 160058......... 01.6642 18.42 160146......... 01.4124 15.32
140212....................... 01.3189 22.65 150032.......... 01.7894 18.85 150112......... 01.2207 16.78 160060......... 01.0892 13.82 160147......... 01.2670 15.41
140213....................... 01.2806 20.44 150033.......... 01.6083 20.07 150113......... 01.1860 16.78 160061......... 01.0020 14.19 160151......... 01.0767 12.75
140215....................... 01.1642 13.22 150034.......... 01.3961 18.15 150114......... 01.0330 13.44 160062......... 00.9619 11.95 160152......... 01.0085 13.30
140217....................... 01.2322 20.90 150035.......... 01.4087 17.90 150115......... 01.3933 17.31 160063......... 01.2910 14.24 160153......... 01.7014 17.05
140218....................... 01.0541 13.64 150036.......... 01.0486 17.35 150122......... 01.1412 15.83 160064......... 01.6406 16.37 170001......... 01.2028 15.90
140220....................... 01.1056 14.22 150037.......... 01.2673 17.06 150123......... 01.1642 12.81 160065......... 01.0735 14.51 170004......... 01.0851 13.18
140223....................... 01.5438 ....... 150038.......... 01.2744 16.27 150124......... 01.1229 15.00 160066......... 01.1266 14.06 170006......... 01.2031 13.48
140224....................... 01.3604 22.10 150039.......... 01.0121 14.51 150125......... 01.4243 18.09 160067......... 01.3705 16.70 170008......... 00.9823 13.35
140228....................... 01.7003 17.36 150042.......... 01.2850 15.47 150126......... 01.5058 19.24 160068......... 01.1116 13.30 170009......... 01.1211 16.81
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
170010....................... 01.2608 16.38 170090.......... 01.1085 09.58 180012......... 01.3389 17.14 180104......... 01.5043 16.55 190064......... 01.5583 17.46
170011....................... 01.4071 14.59 170092.......... 00.8754 11.45 180013......... 01.4998 17.38 180105......... 00.9304 12.23 190065......... 01.4754 15.75
170012....................... 01.4843 15.48 170093.......... 00.9342 11.58 180014......... 01.6064 18.86 180106......... 00.9106 12.65 190071......... 00.8641 11.38
170013....................... 01.3169 13.27 170094.......... 01.0452 12.81 180015......... 01.2489 14.91 180108......... 00.8486 12.49 190077......... 00.9246 13.41
170014....................... 01.0405 15.18 170095.......... 01.0812 13.80 180016......... 01.3171 14.91 180115......... 01.0261 13.72 190078......... 01.1324 11.21
170015....................... 00.9820 13.74 170097.......... 01.0300 13.42 180017......... 01.2806 13.52 180116......... 01.3689 14.92 190079......... 01.2666 14.76
170016....................... 01.6627 21.80 170098.......... 01.0817 16.21 180018......... 01.2192 15.73 180117......... 01.1619 16.14 190081......... 00.8838 09.89
170017....................... 01.1657 14.73 170099.......... 01.3324 11.00 180019......... 01.3403 17.22 180118......... 01.0536 11.72 190083......... 00.9429 12.45
170018....................... 01.0727 12.23 170100.......... 01.0203 14.63 180020......... 01.0315 15.37 180120......... 01.0378 12.49 190086......... 01.3598 14.02
170019....................... 01.1696 15.13 170101.......... 00.9101 14.13 180021......... 01.1795 13.25 180121......... 01.2234 13.09 190088......... 01.1892 16.01
170020....................... 01.3199 14.54 170102.......... 01.0187 12.78 180023......... 00.8295 11.27 180122......... 01.0373 14.67 190089......... 01.1201 09.60
170022....................... 01.1704 14.15 170103.......... 01.2458 15.28 180024......... 01.3845 15.69 180123......... 01.4607 19.39 190090......... 01.0660 15.75
170023....................... 01.4044 15.57 170104.......... 01.4205 19.52 180025......... 01.1284 16.18 180124......... 01.4836 16.00 190092......... 01.3355 20.14
170024....................... 01.1640 12.71 170105.......... 01.0303 14.45 180026......... 01.1086 13.66 180125......... 00.9440 16.23 190095......... 00.9950 14.04
170025....................... 01.1596 18.37 170106.......... 00.8419 12.54 180027......... 01.2742 14.17 180126......... 01.1707 11.90 190098......... 01.5272 17.56
170026....................... 01.0181 16.38 170108.......... 00.9468 10.88 180028......... 01.0014 16.19 180127......... 01.2444 16.63 190099......... 01.1506 17.31
170027....................... 01.3677 15.02 170109.......... 01.0506 14.67 180029......... 01.2273 15.99 180128......... 01.1902 15.40 190102......... 01.5823 16.15
170030....................... 01.0391 13.61 170110.......... 01.0039 13.62 180030......... 01.1759 12.89 180129......... 01.0293 13.93 190103......... 00.8416 09.66
170031....................... 00.9148 12.36 170112.......... 00.9127 13.44 180031......... 01.0226 12.38 180130......... 01.4291 17.87 190106......... 01.1367 17.27
170032....................... 01.1156 14.18 170113.......... 01.1547 13.43 180032......... 00.9954 15.30 180132......... 01.2480 15.19 190109......... 01.2092 13.68
170033....................... 01.3483 14.08 170114.......... 00.9562 12.96 180033......... 01.1235 12.57 180133......... 01.2433 20.73 190110......... 00.9491 11.96
170034....................... 00.9541 13.74 170115.......... 00.9903 11.01 180034......... 01.0753 13.61 180134......... 01.0116 13.71 190111......... 01.5215 17.24
170035....................... 00.9390 12.37 170116.......... 01.0372 13.94 180035......... 01.5699 18.26 180136......... 01.5878 16.63 190112......... 01.5163 20.35
170036....................... 00.8720 12.31 170117.......... 01.0112 12.63 180036......... 01.2440 17.36 180137......... 01.6535 16.82 190113......... 01.3665 17.85
170037....................... 01.1255 15.02 170119.......... 00.9561 11.32 180037......... 01.2889 20.29 180138......... 01.2129 17.02 190114......... 01.0055 11.51
170038....................... 00.9185 10.94 170120.......... 01.2849 14.66 180038......... 01.4243 14.73 180139......... 01.0726 16.41 190115......... 01.2502 16.88
170039....................... 01.1367 11.69 170122.......... 01.8944 19.69 180040......... 02.0334 19.04 180140......... 01.0095 ....... 190116......... 01.3017 14.97
170040....................... 01.5625 18.21 170123.......... 01.7747 17.69 180041......... 01.0945 13.03 190001......... 00.9375 16.35 190118......... 01.0495 11.87
170041....................... 00.9823 11.41 170124.......... 00.9503 11.92 180042......... 01.1163 13.43 190002......... 01.6513 16.28 190120......... 00.9247 12.89
170043....................... 00.9081 13.41 170126.......... 00.9191 11.07 180043......... 01.0156 15.31 190003......... 01.4519 17.16 190122......... 01.2572 13.85
170044....................... 01.1101 14.73 170128.......... 01.0769 14.31 180044......... 01.0359 14.68 190004......... 01.3759 14.75 190124......... 01.5739 18.80
170045....................... 01.0299 10.95 170131.......... 01.0980 10.54 180045......... 01.2057 16.78 190005......... 01.6645 14.94 190125......... 01.5811 16.74
170049....................... 01.3313 18.05 170133.......... 01.1443 14.09 180046......... 01.2012 16.81 190006......... 01.2072 14.50 190128......... 01.2060 17.04
170050....................... 00.8380 09.63 170134.......... 00.9114 12.10 180047......... 01.0191 13.79 190007......... 01.0078 12.79 190130......... 00.9913 11.74
170051....................... 00.9598 13.31 170137.......... 01.1842 16.81 180048......... 01.1403 15.53 190008......... 01.6528 17.79 190131......... 01.2797 17.33
170052....................... 01.0682 13.31 170139.......... 00.9877 11.66 180049......... 01.3563 14.47 190009......... 01.2058 13.40 190133......... 01.0482 15.09
170053....................... 01.0069 13.09 170140.......... 01.0533 11.17 180050......... 01.2697 15.58 190010......... 01.0884 14.69 190134......... 00.9967 12.16
170054....................... 01.0848 12.86 170142.......... 01.2641 16.10 180051......... 01.4187 14.35 190011......... 01.1233 14.08 190135......... 01.4063 21.99
170055....................... 01.0698 17.05 170143.......... 01.1251 12.53 180053......... 01.1091 14.22 190013......... 01.4220 15.27 190136......... 01.1262 10.66
170056....................... 00.9402 10.99 170144.......... 01.6112 18.74 180054......... 01.1611 14.02 190014......... 01.0578 15.36 190138......... 00.6897 15.62
170057....................... 01.0566 13.75 170145.......... 01.1694 17.02 180055......... 01.0370 13.61 190015......... 01.2421 16.38 190140......... 00.9431 11.60
170058....................... 01.1738 17.54 170146.......... 01.4168 17.58 180056......... 01.1099 16.68 190017......... 01.3736 17.22 190142......... 00.9421 12.20
170060....................... 01.1313 12.73 170147.......... 01.2245 18.33 180058......... 01.0090 12.85 190018......... 01.1816 13.78 190144......... 01.2097 18.82
170061....................... 01.1593 12.59 170148.......... 01.4763 18.35 180059......... 00.9670 11.98 190019......... 01.5042 17.57 190145......... 00.9824 13.77
170062....................... 00.9501 10.45 170150.......... 01.0726 13.13 180060......... 00.7427 13.48 190020......... 01.2002 15.83 190146......... 01.5901 18.99
170063....................... 00.8965 09.30 170151.......... 01.0012 11.69 180063......... 00.9649 10.28 190025......... 01.2859 12.36 190147......... 00.9911 13.30
170064....................... 00.9513 11.38 170152.......... 00.9801 13.27 180064......... 01.2906 14.40 190026......... 01.4470 15.65 190148......... 00.8975 11.81
170066....................... 00.9908 12.26 170160.......... 01.0468 11.25 180065......... 00.9809 09.05 190027......... 01.4852 15.62 190149......... 00.9959 11.02
170067....................... 01.0357 11.05 170164.......... 01.0426 13.87 180066......... 01.2068 16.87 190029......... 01.1320 14.09 190151......... 01.1518 12.30
170068....................... 01.3949 14.01 170166.......... 01.1504 13.49 180067......... 01.8783 15.96 190033......... 00.9721 09.64 190152......... 01.4522 20.50
170069....................... 01.1769 13.20 170168.......... 00.9486 09.97 180069......... 01.0397 16.08 190034......... 01.2434 14.93 190155......... 00.9203 10.54
170070....................... 01.0225 11.83 170171.......... 01.0889 11.15 180070......... 01.0977 14.86 190035......... 01.4128 20.27 190156......... 00.8945 11.89
170072....................... 00.9565 11.53 170172.......... 00.9841 11.07 180072......... 01.0513 13.80 190036......... 01.6475 18.96 190158......... 01.2308 20.36
170073....................... 01.0984 12.66 170174.......... 01.0890 11.58 180075......... 00.9736 13.08 190037......... 00.9653 11.05 190160......... 01.2187 15.56
170074....................... 01.1552 12.86 170175.......... 01.2928 16.30 180078......... 01.1230 17.35 190039......... 01.4080 16.41 190161......... 01.0441 12.98
170075....................... 00.8720 10.55 170176.......... 01.5021 18.40 180079......... 01.2486 13.22 190040......... 01.3863 19.03 190162......... 01.1806 21.04
170076....................... 01.0770 11.15 170181.......... 01.1668 ....... 180080......... 01.0636 15.16 190041......... 01.4973 19.72 190164......... 01.2246 16.86
170077....................... 00.9689 11.12 170182.......... 00.8647 ....... 180085......... 01.2892 17.49 190043......... 01.1348 12.38 190166......... 01.0758 14.81
170079....................... 01.0810 11.81 170183.......... 02.1585 ....... 180087......... 01.0887 13.72 190044......... 01.1634 18.27 190167......... 01.2058 16.09
170080....................... 00.9459 11.05 180001.......... 01.2246 16.18 180088......... 01.5722 19.42 190045......... 01.3672 19.09 190170......... 00.9592 12.34
170081....................... 00.9294 10.42 180002.......... 01.0070 17.16 180092......... 01.0482 14.43 190046......... 01.4814 17.16 190173......... 01.4578 19.47
170082....................... 01.0577 10.60 180004.......... 01.0888 13.51 180093......... 01.3617 14.72 190048......... 01.0669 14.55 190175......... 01.2835 ......
170084....................... 00.9862 11.06 180005.......... 01.0390 17.40 180094......... 01.0163 11.93 190049......... 00.9644 14.74 190176......... 01.7028 18.06
170085....................... 00.9109 12.01 180006.......... 00.9063 08.63 180095......... 01.1664 12.78 190050......... 01.0420 13.90 190177......... 01.6125 22.02
170086....................... 01.7190 18.04 180007.......... 01.5485 14.17 180099......... 01.1988 11.72 190053......... 01.0567 11.98 190178......... 00.9868 11.20
170087....................... 01.4582 18.87 180009.......... 01.3310 17.70 180101......... 01.3486 18.84 190054......... 01.4052 13.67 190182......... 01.1720 20.12
170088....................... 00.9139 10.59 180010.......... 01.8382 16.91 180102......... 01.5215 15.95 190059......... 00.9447 13.58 190183......... 01.1294 13.43
170089....................... 01.0037 14.21 180011.......... 01.1737 15.71 180103......... 02.0850 18.62 190060......... 01.4907 16.51 190184......... 01.0550 12.13
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[[Page 27511]]
Page 7 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
190185....................... 01.3116 19.03 210004.......... 01.3245 20.30 220030......... 01.0852 16.42 220171......... 01.6972 22.55 230103......... 01.0124 17.37
190186....................... 00.9539 11.69 210005.......... 01.2407 17.70 220031......... 01.8518 27.21 220897......... 04.8084 ....... 230104......... 01.6163 20.32
190187....................... 00.7801 14.05 210006.......... 01.1291 16.84 220033......... 01.3898 19.40 230001......... 01.2015 15.98 230105......... 01.6088 19.46
190189....................... 00.9445 14.54 210007.......... 01.6215 18.82 220035......... 01.2698 19.72 230002......... 01.2238 19.28 230106......... 01.1784 18.07
190190....................... 00.9291 18.74 210008.......... 01.3146 21.21 220036......... 01.6218 23.26 230003......... 01.0945 18.07 230107......... 00.8964 12.56
190191....................... 01.3068 18.47 210009.......... 01.7134 18.57 220038......... 01.2841 21.85 230004......... 01.6105 20.95 230108......... 01.2432 16.64
190194....................... 01.1471 19.16 210010.......... 01.1960 17.00 220041......... 01.2492 20.87 230005......... 01.2825 18.02 230110......... 01.3309 17.10
190196....................... 00.9097 16.46 210011.......... 01.2110 20.12 220042......... 01.2078 24.10 230006......... 01.1303 16.19 230111......... 00.9772 15.13
190197....................... 01.2655 18.80 210012.......... 01.4840 21.27 220046......... 01.3942 21.48 230007......... 01.0869 16.51 230113......... 00.9511 17.66
190199....................... 01.3623 ....... 210013.......... 01.2780 20.65 220049......... 01.2664 21.58 230013......... 01.2659 20.70 230114......... 00.6368 23.27
190200....................... 01.5241 21.33 210015.......... 01.2720 18.48 220050......... 01.0888 17.45 230015......... 01.1338 18.01 230115......... 01.0164 15.14
190201....................... 01.2315 18.24 210016.......... 01.7279 20.37 220051......... 01.2702 19.70 230017......... 01.5125 20.40 230116......... 00.9155 15.58
190202....................... 01.4459 18.34 210017.......... 01.1256 15.35 220052......... 01.2994 22.76 230019......... 01.5077 20.50 230117......... 01.9674 23.81
190203....................... 01.6074 19.50 210018.......... 01.2414 20.93 220053......... 01.2564 18.86 230020......... 01.7180 21.17 230118......... 01.2419 17.25
190204....................... 01.5314 20.12 210019.......... 01.4011 17.42 220055......... 01.3486 20.61 230021......... 01.6010 17.25 230119......... 01.3145 21.13
190205....................... 01.8790 17.63 210022.......... 01.4536 20.07 220057......... 01.4381 20.91 230022......... 01.2422 17.62 230120......... 01.2315 19.00
190206....................... 01.4995 21.17 210023.......... 01.2956 20.31 220058......... 01.0650 17.55 230024......... 01.4216 21.79 230121......... 01.2320 19.67
190207....................... 01.1825 19.43 210024.......... 01.5336 18.06 220060......... 01.2565 24.78 230027......... 01.0587 16.25 230122......... 01.3296 18.32
190208....................... 00.8198 10.36 210025.......... 01.3227 17.84 220062......... 00.6021 19.30 230029......... 01.5998 20.91 230124......... 01.1555 16.49
190218....................... 01.1389 15.05 210026.......... 01.3187 24.54 220063......... 01.2909 18.42 230030......... 01.2415 16.55 230125......... 01.3676 12.83
190223....................... 00.5039 09.72 210027.......... 01.2046 17.10 220064......... 01.2167 20.66 230031......... 01.4660 18.32 230128......... 01.3700 19.33
190227....................... 00.8050 30.01 210028.......... 01.2256 16.66 220065......... 01.2182 20.00 230032......... 01.7444 18.97 230129......... 01.8923 19.07
190230....................... 00.8737 ....... 210029.......... 01.3064 20.04 220066......... 01.2760 19.39 230034......... 01.1948 16.64 230130......... 01.6884 22.37
190231....................... 01.2825 ....... 210030.......... 01.0993 15.77 220067......... 01.2944 22.82 230035......... 01.1377 15.84 230132......... 01.5373 22.92
190232....................... 01.6623 ....... 210031.......... 01.6370 16.97 220068......... 00.5244 15.95 230036......... 01.2807 19.78 230133......... 01.2350 14.06
190233....................... 01.0997 ....... 210032.......... 01.2096 18.42 220070......... 01.2635 17.77 230037......... 01.1606 16.96 230134......... 01.1081 15.87
200001....................... 01.2712 15.74 210033.......... 01.1818 17.38 220071......... 01.8550 24.38 230038......... 01.6451 21.18 230135......... 01.1885 19.88
200002....................... 01.0212 16.15 210034.......... 01.3996 20.29 220073......... 01.3882 25.34 230040......... 01.1976 18.35 230137......... 01.1691 17.78
200003....................... 01.1264 15.90 210035.......... 01.1952 17.25 220074......... 01.2614 21.18 230041......... 01.2085 18.20 230141......... 01.6883 20.84
200006....................... 01.0731 14.95 210037.......... 01.2887 16.14 220075......... 01.3228 20.09 230042......... 01.1542 19.03 230142......... 01.2092 18.71
200007....................... 01.0066 15.63 210038.......... 01.3413 19.90 220076......... 01.1851 22.47 230046......... 01.8239 24.65 230143......... 01.1481 15.23
200008....................... 01.2497 18.34 210039.......... 01.1613 15.25 220077......... 01.7122 22.32 230047......... 01.3070 19.61 230144......... 01.1092 21.06
200009....................... 01.7602 19.84 210040.......... 01.2993 20.32 220079......... 01.1880 21.28 230053......... 01.5387 23.82 230145......... 01.1742 15.41
200012....................... 01.1641 16.11 210043.......... 01.2569 20.04 220080......... 01.2773 17.77 230054......... 01.8228 19.74 230146......... 01.2845 19.49
200013....................... 01.1401 15.32 210044.......... 01.2000 20.28 220081......... 00.9446 23.55 230055......... 01.1760 17.36 230147......... 01.4742 19.34
200015....................... 01.2358 17.15 210045.......... 01.0148 11.73 220082......... 01.2902 19.28 230056......... 00.9776 14.17 230149......... 01.2419 14.92
200016....................... 01.0350 16.10 210046.......... 01.1079 12.34 220083......... 01.1831 19.80 230058......... 01.0786 17.42 230151......... 01.3631 21.32
200017....................... 01.2447 16.86 210048.......... 01.1746 22.47 220084......... 01.2425 22.24 230059......... 01.4842 19.00 230153......... 01.1118 15.61
200018....................... 01.1602 14.27 210049.......... 01.1517 16.57 220086......... 01.5483 24.60 230060......... 01.2882 16.90 230154......... 00.9493 12.09
200019....................... 01.2486 18.01 210051.......... 01.4541 13.94 220088......... 01.5778 21.76 230062......... 01.0291 10.93 230155......... 00.9752 13.80
200020....................... 01.1930 19.86 210054.......... 01.2790 20.17 220089......... 01.3304 22.99 230063......... 01.3106 18.41 230156......... 01.6989 21.57
200021....................... 01.1723 17.66 210055.......... 01.2914 22.48 220090......... 01.2260 20.78 230065......... 01.4805 18.63 230157......... 01.2084 19.67
200023....................... 00.8814 14.61 210056.......... 01.4132 16.51 220092......... 01.2533 20.86 230066......... 01.3629 17.55 230159......... 01.3614 18.93
200024....................... 01.2940 19.16 210057.......... 01.3587 ....... 220094......... 01.2679 19.76 230068......... 01.4269 22.29 230162......... 00.9841 13.73
200025....................... 01.2732 18.81 210058.......... 01.6842 18.09 220095......... 01.2234 17.77 230069......... 01.1751 18.86 230165......... 01.8763 20.92
200026....................... 01.0896 15.20 210059.......... 01.2581 21.91 220098......... 01.2884 19.81 230070......... 01.4926 19.30 230167......... 01.3662 19.18
200027....................... 01.1423 16.51 210060.......... 01.1731 25.28 220099......... 01.1644 15.97 230071......... 01.1363 20.78 230169......... 01.4366 21.16
200028....................... 00.9339 14.83 210061.......... 01.0980 14.25 220100......... 01.2619 23.48 230072......... 01.2879 18.87 230171......... 00.9849 14.18
200031....................... 01.2965 14.96 220001.......... 01.1636 20.98 220101......... 01.5059 22.58 230075......... 01.5257 19.29 230172......... 01.3176 17.85
200032....................... 01.3588 17.72 220002.......... 01.5368 21.62 220104......... 01.2419 23.12 230076......... 01.3128 21.53 230174......... 01.3016 19.11
200033....................... 01.7105 19.57 220003.......... 01.0806 16.92 220105......... 01.2111 21.97 230077......... 01.9772 18.44 230176......... 01.2388 20.89
200034....................... 01.1962 17.19 220004.......... 01.1812 18.85 220106......... 01.2458 21.83 230078......... 01.0869 14.76 230178......... 01.0320 16.02
200037....................... 01.2193 15.53 220006.......... 01.4332 21.79 220107......... 01.1742 18.46 230080......... 01.1933 20.41 230180......... 01.0676 15.03
200038....................... 01.1145 17.66 220008.......... 01.2523 19.26 220108......... 01.1503 20.96 230081......... 01.2191 16.55 230184......... 01.2246 16.99
200039....................... 01.2494 18.06 220010.......... 01.2949 20.94 220110......... 01.9520 30.07 230082......... 01.1643 14.88 230186......... 01.3835 15.81
200040....................... 01.0969 16.12 220011.......... 01.1570 27.95 220111......... 01.2612 21.21 230085......... 01.1115 17.10 230188......... 01.1787 15.49
200041....................... 01.2255 17.37 220012.......... 01.3654 27.84 220116......... 01.9484 23.95 230086......... 00.9885 14.03 230189......... 00.8927 14.50
200043....................... 00.5362 16.96 220015.......... 01.1767 20.35 220118......... 02.0446 26.47 230087......... 01.0641 13.65 230190......... 01.0483 22.66
200050....................... 01.2051 16.71 220016.......... 01.3547 20.16 220119......... 01.3255 24.40 230089......... 01.3379 21.55 230191......... 00.8947 14.99
200051....................... 00.9656 17.70 220017.......... 01.4233 23.78 220123......... 01.0371 23.85 230092......... 01.3295 17.77 230193......... 01.2340 16.03
200052....................... 00.9605 13.07 220019.......... 01.1716 17.06 220126......... 01.3077 19.39 230093......... 01.2320 17.37 230194......... 01.2090 14.37
200055....................... 01.1609 14.56 220020.......... 01.2174 18.47 220128......... 01.1494 20.85 230095......... 01.2251 15.53 230195......... 01.2803 19.80
200062....................... 00.9155 14.64 220021.......... 01.3823 23.21 220133......... 00.8435 30.53 230096......... 01.1954 19.85 230197......... 01.2564 22.00
200063....................... 01.1630 16.63 220023.......... 01.1522 19.37 220135......... 01.2581 23.97 230097......... 01.5433 17.75 230199......... 01.1386 17.72
200066....................... 01.1762 14.34 220024.......... 01.1696 20.14 220153......... 01.0459 19.74 230099......... 01.2223 19.06 230201......... 01.2166 14.02
210001....................... 01.4081 17.94 220025.......... 01.1948 18.87 220154......... 00.8972 18.96 230100......... 01.1604 15.19 230204......... 01.3584 19.78
210002....................... 01.9534 16.84 220028.......... 01.4680 22.20 220162......... 01.0891 ....... 230101......... 01.0566 16.79 230205......... 01.0607 14.54
210003....................... 01.5503 22.97 220029.......... 01.1933 22.25 220163......... 02.0719 24.73 230102......... 01.1047 ....... 230207......... 01.2544 19.85
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[[Page 27512]]
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
230208....................... 01.1783 16.10 240047.......... 01.5215 18.27 240132......... 01.2422 20.49 250034......... 01.5418 12.99 250138......... 01.3553 16.91
230211....................... 00.9786 13.86 240048.......... 01.2786 20.43 240133......... 01.1715 16.16 250035......... 00.9041 11.82 250140......... 00.9213 09.37
230212....................... 01.0964 21.13 240049.......... 01.7763 20.33 240135......... 00.8386 11.38 250036......... 00.9863 11.34 250141......... 01.2142 15.50
230213....................... 01.0251 12.69 240050.......... 01.1234 19.89 240137......... 01.2521 15.40 250037......... 00.8717 09.53 250144......... 00.9383 11.18
230216....................... 01.5363 17.91 240051.......... 00.9749 15.97 240138......... 00.8953 13.09 250038......... 00.9909 12.52 250145......... 00.9362 ......
230217....................... 01.2142 18.06 240052.......... 01.2480 17.21 240139......... 00.9551 14.24 250039......... 01.0004 11.71 250146......... 01.0020 12.89
230219....................... 01.0153 15.18 240053.......... 01.5190 19.67 240141......... 01.0836 19.12 250040......... 01.2911 15.65 250148......... 01.1589 ......
230221....................... 01.1831 18.15 240056.......... 01.2490 20.13 240142......... 01.1491 15.16 250042......... 01.1491 13.78 250149......... 00.9157 ......
230222....................... 01.3602 18.98 240057.......... 01.7418 22.04 240143......... 01.0673 12.48 250043......... 01.0303 10.49 260001......... 01.6548 15.06
230223....................... 01.3164 19.85 240058.......... 00.9730 09.64 240144......... 00.9419 13.39 250044......... 00.9825 13.98 260002......... 01.4785 20.05
230227....................... 01.5246 22.00 240059.......... 01.1011 17.98 240145......... 00.9681 12.37 250045......... 01.1454 17.17 260003......... 00.9487 12.45
230228....................... 01.2133 17.29 240061.......... 01.7409 20.93 240146......... 00.9270 17.20 250047......... 00.9527 09.12 260004......... 01.0315 11.86
230230....................... 01.5449 20.38 240063.......... 01.4559 20.88 240148......... 00.9433 11.34 250048......... 01.4527 13.51 260005......... 01.6121 19.68
230232....................... 01.0330 15.87 240064.......... 01.2630 18.13 240150......... 00.8874 11.72 250049......... 00.9058 09.93 260006......... 01.5286 16.72
230235....................... 01.1141 14.65 240065.......... 01.1480 11.14 240152......... 01.0177 17.85 250050......... 01.2448 12.30 260007......... 01.4659 16.03
230236....................... 01.3372 21.07 240066.......... 01.3895 19.08 240153......... 01.0210 14.30 250051......... 00.8585 09.44 260008......... 01.2051 13.88
230239....................... 01.1697 16.07 240069.......... 01.1596 18.31 240154......... 01.0138 13.15 250057......... 01.1766 14.06 260009......... 01.2372 15.63
230241....................... 01.1519 17.08 240071.......... 01.1245 18.05 240155......... 00.9817 14.39 250058......... 01.1385 13.65 260011......... 01.6786 16.21
230244....................... 01.3177 20.14 240072.......... 01.0272 16.08 240157......... 01.1265 13.92 250059......... 01.0322 12.16 260012......... 01.0505 11.96
230253....................... 01.0740 17.39 240073.......... 00.9172 15.13 240160......... 00.9997 14.65 250060......... 00.8084 12.19 260013......... 01.1491 12.68
230254....................... 01.2799 22.64 240075.......... 01.2180 18.79 240161......... 00.9389 14.56 250061......... 00.8634 10.75 260014......... 01.7751 17.84
230257....................... 01.1068 19.01 240076.......... 01.1373 19.69 240162......... 00.9645 15.28 250063......... 00.8596 12.68 260015......... 01.2666 13.16
230259....................... 01.1982 19.06 240077.......... 01.0463 14.15 240163......... 00.9330 14.10 250065......... 00.8907 11.72 260017......... 01.2286 13.94
230264....................... 00.9438 16.74 240078.......... 01.4536 21.46 240166......... 01.1669 14.67 250066......... 00.9404 12.17 260018......... 00.9652 09.56
230269....................... 01.3034 21.71 240079.......... 01.0176 12.57 240169......... 00.9534 15.25 250067......... 01.1253 14.14 260019......... 00.9816 12.63
230270....................... 01.2162 20.08 240080.......... 01.3774 20.87 240170......... 01.1564 14.42 250068......... 00.8556 11.19 260020......... 01.7259 18.73
230273....................... 01.6607 22.11 240082.......... 01.1194 14.55 240171......... 00.9950 14.02 250069......... 01.1870 13.42 260021......... 01.5153 17.51
230275....................... 00.5787 16.53 240083.......... 01.3925 16.60 240172......... 01.0869 14.50 250071......... 00.9541 08.06 260022......... 01.3501 18.69
230276....................... 00.8129 16.23 240084.......... 01.3436 17.20 240173......... 00.9599 14.82 250072......... 01.2914 16.67 260023......... 01.2567 15.57
230277....................... 01.2425 21.76 240085.......... 00.9247 14.90 240179......... 01.0022 14.30 250076......... 00.9579 10.32 260024......... 01.0210 12.28
230278....................... 02.0914 19.50 240086.......... 01.0520 15.23 240180......... 01.0157 10.51 250077......... 00.9505 11.08 260025......... 01.3121 13.61
230279....................... 00.6989 ....... 240087.......... 01.0824 15.69 240184......... 01.0424 11.31 250078......... 01.4419 14.21 260027......... 01.5941 18.92
230280....................... 01.0281 ....... 240088.......... 01.4444 18.10 240187......... 01.2617 16.56 250079......... 00.8562 15.12 260029......... 01.1264 15.76
230281....................... 01.7080 ....... 240089.......... 01.0010 15.23 240193......... 01.0582 14.73 250081......... 01.3034 15.19 260030......... 01.0891 09.73
240001....................... 01.5708 21.24 240090.......... 01.0970 13.57 240196......... 00.6132 22.50 250082......... 01.2857 12.30 260031......... 01.4989 18.67
240002....................... 01.6938 19.40 240093.......... 01.3186 16.49 240200......... 00.8962 13.34 250083......... 01.0251 11.01 260032......... 01.5795 17.59
240004....................... 01.4661 20.16 240094.......... 01.0543 17.26 240205......... 00.9014 ....... 250084......... 01.0930 13.92 260034......... 00.9785 14.22
240005....................... 00.9960 13.49 240096.......... 01.0160 14.12 240206......... 00.8472 ....... 250085......... 01.0093 11.42 260035......... 01.0729 11.44
240006....................... 01.1385 19.75 240097.......... 01.1270 17.05 240207......... 01.2326 21.47 250088......... 00.9591 15.56 260036......... 01.0628 15.72
240007....................... 01.1171 15.15 240098.......... 00.9677 16.41 240210......... 01.2588 21.44 250089......... 01.0276 11.77 260037......... 01.4003 15.17
240008....................... 01.0569 15.22 240099.......... 01.1143 11.00 240211......... 00.9532 11.18 250093......... 01.1064 12.17 260039......... 01.1432 11.17
240009....................... 00.9895 14.18 240100.......... 01.3089 19.58 240212......... 01.9942 ....... 250094......... 01.2377 14.41 260040......... 01.6075 14.92
240010....................... 01.9742 20.17 240101.......... 01.1581 17.32 250001......... 01.6688 15.91 250095......... 00.9795 13.57 260042......... 01.4257 15.65
240011....................... 01.1400 15.69 240102.......... 00.8915 12.27 250002......... 00.7926 13.34 250096......... 01.2945 16.48 260044......... 01.0361 14.29
240013....................... 01.3150 15.90 240103.......... 01.0772 14.10 250003......... 01.0305 14.13 250097......... 01.1910 13.83 260047......... 01.3634 14.19
240014....................... 01.0820 17.79 240104.......... 01.2345 21.68 250004......... 01.4613 15.12 250098......... 00.8668 13.73 260048......... 01.2847 18.05
240016....................... 01.3076 15.46 240105.......... 01.0028 12.70 250005......... 00.9643 09.15 250099......... 01.2680 12.73 260050......... 01.0968 14.71
240017....................... 01.1439 15.15 240106.......... 01.3245 23.78 250006......... 00.9651 12.27 250100......... 01.2315 14.53 260052......... 01.3337 15.95
240018....................... 01.2866 15.82 240107.......... 00.9788 15.07 250007......... 01.2618 16.88 250101......... 00.9408 09.89 260053......... 01.1331 09.46
240019....................... 01.2275 19.58 240108.......... 00.9539 11.64 250008......... 00.8996 11.36 250102......... 01.5414 14.80 260054......... 01.3206 15.14
240020....................... 01.1482 18.11 240109.......... 00.9922 13.59 250009......... 01.1809 15.04 250104......... 01.3619 15.58 260055......... 01.0378 13.67
240021....................... 00.9369 12.49 240110.......... 01.0305 15.18 250010......... 01.0381 11.07 250105......... 00.9206 13.13 260057......... 01.1548 13.85
240022....................... 01.1174 17.33 240111.......... 00.9867 13.06 250012......... 00.9568 13.77 250107......... 00.9087 14.16 260059......... 01.1275 14.17
240023....................... 01.0074 15.86 240112.......... 01.0531 13.30 250015......... 01.0942 09.75 250109......... 00.9352 11.54 260061......... 01.1793 10.87
240025....................... 01.1734 15.02 240114.......... 00.9888 11.13 250017......... 01.0107 13.77 250112......... 00.9947 14.22 260062......... 01.1602 19.89
240027....................... 01.0011 12.60 240115.......... 01.6063 22.30 250018......... 00.9603 09.81 250117......... 01.0705 13.28 260063......... 01.1913 14.82
240028....................... 01.1386 16.50 240116.......... 00.9465 12.43 250019......... 01.4259 17.43 250119......... 01.2047 10.80 260064......... 01.3295 15.38
240029....................... 01.1610 15.70 240117.......... 01.0697 16.21 250020......... 01.0082 10.70 250120......... 01.0645 12.04 260065......... 01.7778 15.31
240030....................... 01.3037 16.78 240119.......... 00.8486 16.93 250021......... 00.8579 07.74 250122......... 01.2735 15.87 260066......... 01.0927 13.19
240031....................... 00.9361 13.50 240121.......... 00.9008 16.90 250023......... 00.8647 11.22 250123......... 01.3262 17.72 260067......... 00.9820 10.43
240036....................... 01.5543 19.05 240122.......... 01.0504 16.80 250024......... 00.9894 08.25 250124......... 00.9137 10.69 260068......... 01.6715 18.49
240037....................... 01.0408 16.40 240123.......... 01.0498 13.30 250025......... 01.1455 13.58 250125......... 01.3231 18.35 260070......... 01.0862 11.09
240038....................... 01.4454 22.37 240124.......... 01.0139 15.71 250027......... 01.0256 10.40 250126......... 00.9923 10.22 260073......... 00.9681 11.58
240040....................... 01.2251 17.67 240125.......... 00.9399 10.75 250029......... 00.8872 11.87 250127......... 00.7630 ....... 260074......... 01.2427 14.81
240041....................... 01.2877 14.43 240127.......... 01.0142 12.51 250030......... 00.9688 11.39 250128......... 01.1010 12.64 260077......... 01.7271 16.15
240043....................... 01.1990 16.83 240128.......... 01.1180 14.55 250031......... 01.3157 17.20 250131......... 01.0539 09.36 260078......... 01.1782 12.39
240044....................... 01.2046 16.02 240129.......... 01.0153 12.18 250032......... 01.2551 15.70 250134......... 00.9795 12.70 260079......... 00.9824 11.78
240045....................... 01.0655 18.49 240130.......... 01.0151 14.54 250033......... 00.9921 11.57 250136......... 00.7871 16.84 260080......... 00.9654 09.77
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[[Page 27513]]
Page 9 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
260081....................... 01.4971 16.44 270004.......... 01.6477 16.49 280026......... 01.1254 12.80 280115......... 00.9809 13.59 310017......... 01.3295 21.95
260082....................... 01.1231 13.50 270006.......... 01.0290 18.67 280028......... 01.0559 13.64 280117......... 01.2229 14.48 310018......... 01.2194 21.06
260085....................... 01.5684 18.57 270007.......... 00.9630 12.26 280029......... 01.0506 12.62 280118......... 00.9757 13.28 310019......... 01.6403 20.84
260086....................... 01.0649 12.67 270009.......... 01.0387 14.91 280030......... 01.7392 23.13 280119......... 00.8364 ....... 310020......... 01.1974 19.66
260089....................... 00.9614 13.31 270011.......... 01.1242 ....... 280031......... 01.0575 12.48 280123......... 00.7918 ....... 310021......... 01.3472 21.15
260091....................... 01.6022 18.86 270012.......... 01.5945 17.10 280032......... 01.3182 15.11 290001......... 01.6372 22.35 310022......... 01.2384 19.38
260094....................... 01.1872 14.91 270013.......... 01.2847 16.78 280033......... 00.9766 13.62 290002......... 00.8981 17.99 310024......... 01.2566 22.60
260095....................... 01.4432 16.05 270014.......... 01.7192 15.97 280034......... 01.2078 13.41 290003......... 01.6179 21.15 310025......... 01.2260 21.92
260096....................... 01.5521 21.52 270016.......... 00.8187 11.51 280035......... 00.9433 11.75 290005......... 01.4399 19.66 310026......... 01.2647 21.91
260097....................... 01.1913 15.82 270017.......... 01.2275 18.32 280037......... 01.0146 13.55 290006......... 01.2170 16.54 310027......... 01.3646 18.17
260100....................... 00.9630 13.12 270019.......... 01.0625 13.34 280038......... 01.0763 13.39 290007......... 01.8961 25.07 310028......... 01.1530 20.46
260102....................... 01.0125 16.75 270021.......... 01.1007 15.55 280039......... 01.1970 14.24 290008......... 01.2200 17.14 310029......... 01.8925 20.69
260103....................... 01.3849 16.73 270023.......... 01.2916 18.76 280040......... 01.5940 18.30 290009......... 01.6244 21.07 310031......... 02.5990 24.14
260104....................... 01.6403 19.57 270024.......... 00.9931 11.15 280041......... 01.0014 10.95 290010......... 01.2053 19.33 310032......... 01.2921 20.00
260105....................... 01.8664 19.47 270026.......... 00.8654 11.95 280042......... 01.0880 13.22 290011......... 00.8812 14.39 310034......... 01.2545 19.14
260107....................... 01.3815 18.77 270027.......... 01.0389 12.69 280043......... 01.1268 12.75 290012......... 01.4385 19.97 310036......... 01.2092 18.44
260108....................... 01.8100 17.90 270028.......... 01.0741 14.91 280045......... 01.1401 13.48 290013......... 01.0185 14.85 310037......... 01.3076 24.97
260109....................... 00.9959 11.92 270029.......... 00.9031 14.51 280046......... 01.0732 11.09 290014......... 01.0444 16.52 310038......... 01.9146 22.82
260110....................... 01.6120 14.16 270031.......... 00.8747 09.71 280047......... 01.1620 15.70 290015......... 00.9730 15.38 310039......... 01.2871 20.51
260111....................... 00.9980 08.04 270032.......... 01.1788 16.46 280048......... 01.0800 11.17 290016......... 01.1392 18.71 310040......... 01.2688 23.12
260112....................... 01.4171 17.75 270033.......... 00.8766 11.39 280049......... 01.0408 13.82 290019......... 01.2774 17.92 310041......... 01.3218 22.90
260113....................... 01.1053 14.05 270035.......... 01.0275 15.87 280050......... 00.9290 13.11 290020......... 01.0859 17.65 310042......... 01.2459 21.74
260115....................... 01.2345 14.63 270036.......... 00.9483 10.42 280051......... 01.0735 13.72 290021......... 01.5601 19.17 310043......... 01.2080 20.60
260116....................... 01.1223 13.70 270039.......... 01.0661 11.99 280052......... 01.0491 11.85 290022......... 01.7399 22.47 310044......... 01.3055 20.16
260119....................... 01.1640 14.93 270040.......... 01.0825 17.60 280054......... 01.2628 17.92 290027......... 00.9567 14.68 310045......... 01.3849 25.76
260120....................... 01.1599 15.72 270041.......... 01.0693 11.14 280055......... 00.9347 11.63 290029......... 00.9400 ....... 310047......... 01.3410 23.05
260122....................... 01.1502 13.12 270044.......... 01.1913 13.40 280056......... 00.9886 10.99 290032......... 01.4149 18.66 310048......... 01.1852 20.69
260123....................... 01.0312 11.56 270046.......... 00.9346 13.50 280057......... 01.0055 14.48 290038......... 01.1064 ....... 310049......... 01.3294 23.54
260127....................... 00.9514 13.71 270048.......... 01.0940 13.30 280058......... 01.3123 13.75 300001......... 01.3957 20.70 310050......... 01.2677 20.88
260128....................... 00.9851 08.95 270049.......... 01.8346 18.19 280060......... 01.5884 18.35 300003......... 01.8607 20.92 310051......... 01.3207 24.26
260129....................... 01.2124 13.51 270050.......... 01.0380 15.96 280061......... 01.4628 14.76 300005......... 01.2620 18.65 310052......... 01.2545 20.53
260131....................... 01.2940 16.32 270051.......... 01.2980 17.65 280062......... 01.2187 11.92 300006......... 01.1221 16.24 310054......... 01.2880 23.19
260134....................... 01.1526 13.82 270052.......... 01.0663 18.02 280064......... 01.0759 12.61 300007......... 01.1527 16.76 310056......... 01.1826 20.11
260137....................... 01.2614 13.71 270053.......... 00.8678 09.53 280065......... 01.2879 16.22 300008......... 01.2481 16.95 310057......... 01.2933 20.10
260138....................... 01.9711 20.66 270057.......... 01.1715 17.35 280066......... 01.0191 11.38 300009......... 01.0977 17.45 310058......... 01.1025 25.35
260141....................... 01.8695 16.53 270058.......... 00.9411 11.20 280068......... 00.9659 09.31 300010......... 01.2364 17.80 310060......... 01.2116 17.55
260142....................... 01.1566 14.50 270059.......... 00.8676 19.21 280070......... 01.0724 10.75 300011......... 01.3481 21.53 310061......... 01.2085 19.85
260143....................... 00.9463 10.52 270060.......... 00.9702 11.92 280073......... 01.0386 12.78 300012......... 01.2749 21.64 310062......... 01.2936 23.90
260147....................... 01.0469 12.81 270063.......... 00.8933 12.94 280074......... 01.1165 12.87 300013......... 01.2241 16.87 310063......... 01.3528 20.78
260148....................... 00.9572 09.33 270068.......... 00.8629 12.38 280075......... 01.2096 12.90 300014......... 01.2293 18.41 310064......... 01.2956 21.35
260158....................... 01.1275 11.80 270072.......... 00.8605 14.88 280076......... 01.0719 12.54 300015......... 01.1807 17.56 310067......... 01.3198 21.14
260159....................... 01.2924 18.02 270073.......... 01.0764 11.06 280077......... 01.3635 17.36 300016......... 01.3137 17.41 310069......... 01.1292 18.19
260160....................... 01.0663 14.07 270074.......... 00.8832 ....... 280079......... 01.0636 09.40 300017......... 01.2137 20.49 310070......... 01.3977 22.16
260162....................... 01.7006 17.70 270075.......... 00.8610 ....... 280080......... 01.0860 11.34 300018......... 01.2397 18.85 310072......... 01.3053 20.74
260163....................... 01.3037 14.11 270076.......... 00.8395 ....... 280081......... 01.5614 17.24 300019......... 01.2613 18.43 310073......... 01.5567 22.31
260164....................... 01.0000 12.07 270079.......... 00.9594 13.36 280082......... 01.0967 13.03 300020......... 01.2666 19.78 310074......... 01.4153 21.08
260166....................... 01.2144 21.51 270080.......... 01.1499 14.27 280083......... 01.0671 15.64 300021......... 01.1635 15.69 310075......... 01.2965 21.67
260172....................... 01.0176 12.07 270081.......... 01.0780 09.77 280084......... 01.0314 10.92 300022......... 01.0939 17.08 310076......... 01.3883 28.16
260173....................... 00.9560 11.15 270082.......... 01.0050 16.10 280085......... 00.7201 14.72 300023......... 01.3251 20.13 310077......... 01.5000 23.09
260175....................... 01.1270 14.60 270083.......... 01.1179 10.96 280088......... 01.8180 17.33 300024......... 01.2662 16.56 310078......... 01.3399 22.70
260176....................... 01.6758 18.44 270084.......... 00.9031 12.77 280089......... 01.0614 13.79 300028......... 01.2716 15.52 310081......... 01.2643 20.80
260177....................... 01.3871 19.46 280001.......... 01.0866 14.11 280090......... 00.9838 11.70 300029......... 01.3165 21.79 310083......... 01.2405 22.20
260178....................... 01.4760 19.06 280003.......... 01.9467 18.11 280091......... 01.1320 13.17 300033......... 01.1041 13.70 310084......... 01.2611 20.43
260179....................... 01.5653 18.02 280005.......... 01.3791 16.72 280092......... 00.8959 11.63 300034......... 01.9294 21.31 310086......... 01.1743 20.89
260180....................... 01.7024 18.45 280009.......... 01.7304 16.70 280094......... 01.1287 13.55 310001......... 01.7682 24.56 310087......... 01.2357 18.95
260183....................... 01.6443 16.51 280011.......... 00.9606 11.56 280097......... 01.0459 12.56 310002......... 01.7260 25.58 310088......... 01.2439 19.57
260186....................... 01.2600 15.20 280012.......... 01.2348 14.88 280098......... 01.0110 09.68 310003......... 01.2210 23.16 310090......... 01.1901 22.86
260188....................... 01.2714 15.70 280013.......... 02.0127 19.71 280101......... 01.1114 10.92 310005......... 01.2226 19.20 310091......... 01.2170 21.35
260189....................... 00.9400 11.23 280014.......... 01.0034 10.78 280102......... 01.1187 11.77 310006......... 01.2198 19.02 310092......... 01.3046 20.52
260190....................... 01.2072 18.46 280015.......... 01.0314 13.78 280104......... 00.9608 09.88 310008......... 01.2739 21.23 310093......... 01.2163 19.52
260191....................... 01.1707 19.44 280017.......... 01.1537 13.42 280105......... 01.2920 16.46 310009......... 01.2782 21.35 310096......... 01.9004 21.19
260193....................... 01.2240 19.13 280018.......... 01.1931 12.25 280106......... 00.9402 13.23 310010......... 01.2912 21.05 310105......... 01.1999 22.41
260195....................... 01.1660 ....... 280020.......... 01.5257 18.97 280107......... 01.0294 12.36 310011......... 01.3017 21.71 310108......... 01.3824 21.08
260197....................... 01.3182 20.38 280021.......... 01.3499 14.01 280108......... 01.1461 13.26 310012......... 01.5940 23.47 310110......... 01.2143 19.69
260198....................... 01.2213 14.98 280022.......... 00.9770 11.07 280109......... 00.9501 10.61 310013......... 01.2768 19.91 310111......... 01.2557 19.70
260200....................... 01.3554 19.14 280023.......... 01.3780 13.73 280110......... 00.9942 10.88 310014......... 01.7025 23.69 310112......... 01.2426 20.58
270002....................... 01.1911 13.92 280024.......... 01.0114 13.22 280111......... 01.2372 16.06 310015......... 01.7776 24.34 310113......... 01.2089 20.70
270003....................... 01.2465 18.65 280025.......... 00.9810 11.07 280114......... 00.9353 10.26 310016......... 01.2225 22.93 310115......... 01.1943 19.78
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
310116....................... 01.2919 21.67 330028.......... 01.3448 23.76 330132......... 01.1620 13.74 330233......... 01.5441 29.08 330399......... 01.3239 29.65
310118....................... 01.1849 21.86 330029.......... 01.1111 17.36 330133......... 01.3428 28.31 330234......... 02.1918 24.17 340001......... 01.4951 19.39
310119....................... 01.5594 27.27 330030.......... 01.2349 14.89 330135......... 01.2563 16.25 330235......... 01.1332 17.37 340002......... 01.8825 18.53
310120....................... 01.0603 17.24 330033.......... 01.2846 13.46 330136......... 01.2637 20.45 330236......... 01.3832 26.18 340003......... 01.1188 16.56
310121....................... 01.0460 16.61 330034.......... 00.7718 36.61 330140......... 01.7132 17.19 330238......... 01.1820 14.53 340004......... 01.4966 17.21
320001....................... 01.4620 16.76 330036.......... 01.3298 21.00 330141......... 01.3504 23.17 330239......... 01.2013 15.44 340005......... 01.2221 14.57
320002....................... 01.4159 21.55 330037.......... 01.1242 15.17 330144......... 00.9758 13.17 330240......... 01.3354 26.47 340006......... 01.2338 14.56
320003....................... 01.1576 15.57 330038.......... 01.2140 14.91 330148......... 01.0784 14.39 330241......... 01.8652 20.92 340007......... 01.1848 14.81
320004....................... 01.2677 17.86 330039.......... 00.8486 13.18 330151......... 01.0421 13.73 330242......... 01.3516 18.35 340008......... 01.1458 16.48
320005....................... 01.3217 17.80 330041.......... 01.3912 27.81 330152......... 01.4273 27.77 330245......... 01.2716 17.15 340009......... 01.4043 18.58
320006....................... 01.3699 15.02 330043.......... 01.2400 25.15 330153......... 01.6522 17.44 330246......... 01.2502 22.99 340010......... 01.3129 16.41
320009....................... 01.5348 16.75 330044.......... 01.2405 16.99 330154......... 01.5884 ....... 330247......... 00.7071 26.49 340011......... 01.1134 13.98
320011....................... 00.9939 17.79 330045.......... 01.4167 24.83 330157......... 01.3091 18.41 330249......... 01.2314 15.89 340012......... 01.2605 15.82
320012....................... 01.0231 16.57 330046.......... 01.5105 28.39 330158......... 01.3668 24.33 330250......... 01.3166 16.01 340013......... 01.2719 16.58
320013....................... 01.2225 18.28 330047.......... 01.2265 16.63 330159......... 01.3291 17.35 330252......... 00.9141 15.40 340014......... 01.5921 22.15
320014....................... 01.0141 08.42 330048.......... 01.2888 16.10 330160......... 01.4618 26.09 330254......... 01.0327 15.52 340015......... 01.2388 16.44
320016....................... 01.1571 12.00 330049.......... 01.2436 17.52 330161......... 00.7163 16.00 330258......... 01.4234 25.28 340016......... 01.1961 15.18
320017....................... 01.2175 17.67 330053.......... 01.1270 14.39 330162......... 01.2602 26.18 330259......... 01.4434 21.99 340017......... 01.2581 15.69
320018....................... 01.4643 16.61 330055.......... 01.5089 29.02 330163......... 01.2099 17.75 330261......... 01.2224 24.35 340018......... 01.1212 14.78
320019....................... 01.4799 19.01 330056.......... 01.4367 28.30 330164......... 01.3999 18.96 330263......... 00.9948 17.00 340019......... 01.0453 13.69
320021....................... 01.7045 20.62 330057.......... 01.7192 15.43 330166......... 00.9641 13.96 330264......... 01.2753 20.00 340020......... 01.1711 17.33
320022....................... 01.1678 16.34 330058.......... 01.3255 15.69 330167......... 01.6419 27.45 330265......... 01.3114 15.78 340021......... 01.2221 15.08
320023....................... 01.0224 13.29 330059.......... 01.6149 29.66 330169......... 01.4285 31.70 330267......... 01.2789 22.78 340022......... 01.0451 14.56
320030....................... 00.9845 16.54 330061.......... 01.2961 23.38 330171......... 01.2758 21.15 330268......... 00.9689 15.79 340023......... 01.3842 18.44
320031....................... 00.8961 14.78 330062.......... 01.1834 14.99 330175......... 01.1250 14.28 330270......... 01.9667 30.33 340024......... 01.2260 15.05
320032....................... 01.0053 16.66 330064.......... 01.3837 28.38 330177......... 01.0204 12.46 330273......... 01.2909 21.36 340025......... 01.1908 14.15
320033....................... 01.1561 19.23 330065.......... 01.1753 17.14 330179......... 00.8644 14.09 330275......... 01.2168 18.19 340027......... 01.2025 15.46
320035....................... 01.0000 14.82 330066.......... 01.2326 17.26 330180......... 01.1942 16.09 330276......... 01.1889 16.58 340028......... 01.5288 17.48
320037....................... 01.2063 15.17 330067.......... 01.3792 19.68 330181......... 01.3113 28.32 330277......... 01.1317 16.35 340030......... 02.0064 19.06
320038....................... 01.1613 15.62 330072.......... 01.3367 26.92 330182......... 02.5604 26.92 330279......... 01.2905 17.24 340031......... 00.9382 12.56
320046....................... 01.1938 18.23 330073.......... 01.1865 14.20 330183......... 01.4402 18.88 330285......... 01.8179 21.81 340032......... 01.3951 17.87
320048....................... 01.3453 13.90 330074.......... 01.1952 16.89 330184......... 01.3357 25.83 330286......... 01.3134 22.59 340035......... 01.1716 14.97
320056....................... 00.9819 ....... 330075.......... 01.0925 16.48 330185......... 01.2303 24.23 330290......... 01.7595 28.28 340036......... 01.1656 17.04
320057....................... 01.0612 ....... 330078.......... 01.4429 16.90 330186......... 00.9205 18.79 330293......... 01.1658 13.72 340037......... 01.1731 15.50
320058....................... 00.9103 ....... 330079.......... 01.3056 16.60 330188......... 01.1826 17.75 330304......... 01.2716 25.62 340038......... 01.1099 14.52
320059....................... 00.9799 ....... 330080.......... 01.4028 24.95 330189......... 01.3836 16.20 330306......... 01.4564 26.59 340039......... 01.2731 19.18
320060....................... 00.9135 ....... 330082.......... 01.1164 16.29 330191......... 01.2642 17.14 330307......... 01.2198 18.33 340040......... 01.7730 17.75
320061....................... 01.0790 ....... 330084.......... 00.9954 15.59 330193......... 01.2990 27.34 330308......... 01.1771 28.68 340041......... 01.2428 15.99
320062....................... 00.9353 ....... 330085.......... 01.3139 18.66 330194......... 01.8175 26.07 330309......... 01.2301 24.67 340042......... 01.1875 13.80
320063....................... 01.3344 15.84 330086.......... 01.2522 24.13 330195......... 01.6251 29.02 330314......... 01.3625 21.07 340044......... 01.1061 13.26
320065....................... 01.2800 16.76 330088.......... 01.1053 24.41 330196......... 01.3279 25.53 330315......... 01.2528 24.58 340045......... 01.0396 10.95
320067....................... 00.8183 09.19 330090.......... 01.5574 16.86 330197......... 01.0999 14.43 330316......... 01.3007 26.23 340047......... 01.8881 17.90
320068....................... 00.9221 17.98 330091.......... 01.3825 17.64 330198......... 01.3312 22.17 330327......... 00.9294 15.30 340048......... 00.9055 09.39
320069....................... 01.0367 09.08 330092.......... 01.1062 13.64 330199......... 01.4730 24.90 330331......... 01.2281 27.78 340049......... 00.6394 15.10
320070....................... 01.0220 ....... 330094.......... 01.2285 15.57 330201......... 01.5327 27.38 330332......... 01.2569 24.30 340050......... 01.1927 14.69
320074....................... 01.1134 17.15 330095.......... 01.2586 16.43 330202......... 01.4667 25.07 330333......... 01.3666 22.00 340051......... 01.2724 16.23
320079....................... 01.1977 17.41 330096.......... 01.0690 14.47 330203......... 01.4028 19.16 330336......... 01.3373 27.39 340052......... 01.0387 18.62
330001....................... 01.1965 24.84 330097.......... 01.1645 14.51 330204......... 01.4276 24.90 330338......... 01.1337 22.52 340053......... 01.6979 18.94
330002....................... 01.4946 24.26 330100.......... 00.6809 25.95 330205......... 01.1548 19.46 330339......... 00.8047 18.09 340054......... 01.0903 12.68
330003....................... 01.3431 19.29 330101.......... 01.7909 33.09 330208......... 01.2046 23.16 330340......... 01.2007 23.91 340055......... 01.2066 16.69
330004....................... 01.2765 19.10 330102.......... 01.2998 16.32 330209......... 01.1899 21.17 330350......... 01.8078 27.96 340060......... 01.1317 16.38
330005....................... 01.8086 19.53 330103.......... 01.2457 15.94 330211......... 01.2056 16.31 330353......... 01.3988 27.49 340061......... 01.7130 19.20
330006....................... 01.3140 24.11 330104.......... 01.3533 25.44 330212......... 01.1780 20.25 330354......... 01.3850 ....... 340063......... 01.0618 13.01
330007....................... 01.3275 17.39 330106.......... 01.5693 33.04 330213......... 01.1258 16.19 330357......... 01.3770 32.07 340064......... 01.2274 16.89
330008....................... 01.1201 15.74 330107.......... 01.2581 24.38 330214......... 01.7374 28.82 330359......... 00.9481 23.70 340065......... 01.3093 12.82
330009....................... 01.3524 28.08 330108.......... 01.2108 15.85 330215......... 01.2093 15.65 330372......... 01.2689 22.53 340067......... 01.1980 12.84
330010....................... 01.1699 15.34 330111.......... 01.0835 14.62 330218......... 01.1561 17.16 330381......... 01.1775 26.80 340068......... 01.2347 14.09
330011....................... 01.2484 17.22 330114.......... 00.8917 15.48 330219......... 01.6451 18.39 330385......... 01.1714 29.27 340069......... 01.7147 18.31
330012....................... 01.6092 27.82 330115.......... 01.2026 14.46 330221......... 01.3287 26.57 330386......... 01.1388 20.82 340070......... 01.3855 16.89
330013....................... 02.0610 16.84 330116.......... 00.9205 13.82 330222......... 01.2641 15.28 330387......... 00.8466 23.28 340071......... 01.0722 14.30
330014....................... 01.3839 27.12 330118.......... 01.6256 18.16 330223......... 01.0773 15.10 330389......... 01.8147 29.95 340072......... 01.1441 13.86
330016....................... 01.0259 14.55 330119.......... 01.7361 29.88 330224......... 01.2693 18.85 330390......... 01.2508 28.38 340073......... 01.4620 20.47
330019....................... 01.1269 23.60 330121.......... 01.0046 14.35 330225......... 01.1710 23.34 330393......... 01.7066 25.24 340075......... 01.1488 15.98
330020....................... 01.0498 14.20 330122.......... 01.2006 20.92 330226......... 01.2690 16.53 330394......... 01.5060 17.27 340080......... 01.1232 13.55
330023....................... 01.2458 22.76 330125.......... 01.8084 19.69 330229......... 01.3174 14.90 330395......... 01.3465 30.16 340084......... 01.0577 14.51
330024....................... 01.9139 30.03 330126.......... 01.2271 20.35 330230......... 01.5132 26.44 330396......... 01.2729 26.86 340085......... 01.2634 15.46
330025....................... 01.1935 13.80 330127.......... 01.3930 25.99 330231......... 01.1306 27.57 330397......... 01.2901 23.98 340087......... 01.1402 16.80
330027....................... 01.4632 28.56 330128.......... 01.3068 25.26 330232......... 01.2194 15.46 330398......... 01.2229 26.59 340088......... 01.1242 16.32
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[[Page 27515]]
Page 11 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
340089....................... 00.9624 12.28 350011.......... 01.9150 17.37 360036......... 01.3220 17.27 360113......... 01.3029 18.24 360204......... 01.2911 16.96
340090....................... 01.1324 15.49 350012.......... 01.1423 12.36 360037......... 02.1403 20.14 360114......... 01.1471 16.05 360210......... 01.2281 19.23
340091....................... 01.6487 18.32 350013.......... 01.0828 14.58 360038......... 01.5899 17.85 360115......... 01.3208 18.08 360211......... 01.2341 17.25
340093....................... 01.0683 11.60 350014.......... 01.0438 14.29 360039......... 01.2504 15.38 360116......... 01.1336 16.04 360212......... 01.3982 20.25
340094....................... 01.3312 16.83 350015.......... 01.7039 14.44 360040......... 01.3208 17.72 360118......... 01.3257 17.37 360213......... 01.1677 15.77
340096....................... 01.2015 17.18 350016.......... 01.0482 10.35 360041......... 01.3759 18.25 360121......... 01.2853 16.74 360218......... 01.2994 16.21
340097....................... 01.1584 16.04 350017.......... 01.4595 14.52 360042......... 01.1088 16.74 360122......... 01.3802 17.77 360230......... 01.3282 20.27
340098....................... 01.6790 19.05 350018.......... 01.1672 10.67 360044......... 01.1425 15.79 360123......... 01.2539 17.50 360231......... 01.1364 12.45
340099....................... 01.0973 13.36 350019.......... 01.6119 18.69 360045......... 01.4898 19.25 360124......... 01.2571 17.08 360234......... 01.3614 17.90
340101....................... 01.0284 11.11 350020.......... 01.4933 17.82 360046......... 01.1375 18.60 360125......... 01.1173 16.87 360236......... 01.1885 18.56
340104....................... 00.9509 10.60 350021.......... 01.0719 10.94 360047......... 01.2246 13.85 360126......... 01.2013 18.97 360239......... 01.2445 18.70
340105....................... 01.3875 17.75 350023.......... 00.8794 15.59 360048......... 01.7427 21.00 360127......... 01.1556 16.28 360241......... 00.5303 17.69
340106....................... 01.1119 17.79 350024.......... 01.1055 13.69 360049......... 01.2627 17.36 360128......... 01.1296 13.85 360242......... 01.6927 ......
340107....................... 01.3175 16.17 350025.......... 01.0584 12.60 360050......... 01.1772 12.43 360129......... 01.0407 14.06 360243......... 00.7499 14.35
340109....................... 01.3284 15.91 350027.......... 00.9693 12.57 360051......... 01.5377 21.83 360130......... 01.1314 15.16 360244......... 00.7183 16.77
340111....................... 01.1696 13.78 350029.......... 01.0052 12.34 360052......... 01.7099 17.88 360131......... 01.4113 16.27 360245......... 00.8026 12.10
340112....................... 01.2281 14.03 350030.......... 01.0850 16.04 360054......... 01.2577 15.55 360132......... 01.2353 20.78 360246......... 00.8761 15.05
340113....................... 01.9956 19.50 350033.......... 00.9626 13.23 360055......... 01.2369 18.92 360133......... 01.4730 17.61 360247......... 00.4357 ......
340114....................... 01.5144 19.16 350034.......... 01.0422 13.58 360056......... 01.3471 16.92 360134......... 01.5906 18.25 370001......... 01.6940 18.41
340115....................... 01.5599 17.23 350035.......... 00.9058 10.11 360057......... 01.0323 13.04 360135......... 01.1609 17.12 370002......... 01.2409 13.60
340116....................... 01.9326 20.30 350038.......... 01.0433 13.26 360058......... 01.2713 15.35 360136......... 01.0537 14.73 370004......... 01.2787 15.30
340119....................... 01.2864 15.21 350039.......... 00.9735 13.53 360059......... 01.5326 20.00 360137......... 01.5595 18.98 370005......... 01.0310 14.12
340120....................... 01.1407 12.33 350041.......... 01.0473 13.05 360062......... 01.4664 18.40 360140......... 01.0061 15.47 370006......... 01.3098 14.88
340121....................... 01.0454 14.52 350042.......... 01.0545 12.39 360063......... 01.1442 17.19 360141......... 01.4435 19.84 370007......... 01.1454 12.80
340122....................... 00.9955 10.30 350043.......... 01.6433 16.58 360064......... 01.5484 19.65 360142......... 01.0217 14.99 370008......... 01.4101 16.02
340123....................... 01.1301 14.07 350044.......... 00.9167 10.01 360065......... 01.2285 16.97 360143......... 01.2936 17.74 370011......... 01.0535 12.51
340124....................... 01.0290 12.27 350047.......... 01.2270 16.64 360066......... 01.3888 17.16 360144......... 01.3153 20.19 370012......... 00.8431 09.22
340125....................... 01.4128 16.94 350049.......... 01.2236 10.38 360067......... 01.2739 12.11 360145......... 01.6266 16.84 370013......... 01.7649 18.61
340126....................... 01.4341 16.23 350050.......... 00.9361 10.25 360068......... 01.6561 21.91 360147......... 01.2668 15.55 370014......... 01.3220 17.14
340127....................... 01.3124 16.30 350051.......... 00.9479 14.13 360069......... 01.1403 16.38 360148......... 01.0725 16.50 370015......... 01.2733 13.84
340129....................... 01.3428 18.65 350053.......... 01.0745 09.47 360070......... 01.6756 16.57 360149......... 01.1481 20.33 370016......... 01.3805 14.25
340130....................... 01.3270 16.03 350055.......... 00.9216 11.50 360071......... 01.2663 15.42 360150......... 01.2805 17.70 370017......... 01.1032 12.14
340131....................... 01.4309 15.77 350056.......... 00.9559 12.92 360072......... 01.1415 16.29 360151......... 01.3134 16.55 370018......... 01.2603 14.06
340132....................... 01.3108 12.41 350058.......... 00.9358 12.18 360074......... 01.3554 19.15 360152......... 01.4800 17.65 370019......... 01.3065 11.91
340133....................... 01.0442 13.87 350060.......... 00.7458 07.59 360075......... 01.4959 20.80 360153......... 01.1489 13.64 370020......... 01.2921 12.53
340136....................... 00.7885 24.45 350061.......... 01.0638 13.77 360076......... 01.3053 18.84 360154......... 01.0301 12.39 370021......... 00.9804 10.01
340137....................... 01.2184 12.68 350063.......... 00.8926 ....... 360077......... 01.4743 18.59 360155......... 01.3265 18.75 370022......... 01.2770 15.09
340138....................... 01.1777 17.60 350064.......... 00.9587 ....... 360078......... 01.2792 18.97 360156......... 01.3473 16.47 370023......... 01.3268 14.95
340141....................... 01.6350 18.27 350066.......... 00.7912 ....... 360079......... 01.7583 19.31 360159......... 01.1944 18.50 370025......... 01.3983 15.37
340142....................... 01.2013 14.94 360001.......... 01.3143 17.88 360080......... 01.1127 14.39 360161......... 01.2723 18.78 370026......... 01.4214 16.08
340143....................... 01.3902 18.50 360002.......... 01.1965 15.17 360081......... 01.3567 17.92 360162......... 01.2555 17.27 370028......... 01.8667 17.67
340144....................... 01.4374 14.85 360003.......... 01.7521 19.64 360082......... 01.3134 19.81 360163......... 01.8595 19.87 370029......... 01.2233 12.79
340145....................... 01.3310 16.80 360006.......... 01.7493 19.53 360083......... 01.2570 15.49 360164......... 00.8555 13.98 370030......... 01.2426 12.05
340146....................... 01.0146 15.42 360007.......... 01.0552 15.41 360084......... 01.6203 18.16 360165......... 01.2257 14.31 370032......... 01.5278 14.28
340147....................... 01.2935 17.80 360008.......... 01.2985 16.20 360085......... 01.8174 19.63 360166......... 01.1556 15.83 370033......... 01.0835 11.23
340148....................... 01.4339 18.28 360009.......... 01.3946 17.35 360086......... 01.4601 16.75 360169......... 00.9799 16.99 370034......... 01.2667 12.80
340151....................... 01.1224 14.05 360010.......... 01.2275 15.38 360087......... 01.4074 17.32 360170......... 01.2837 16.07 370035......... 01.6190 15.21
340153....................... 01.9701 21.08 360011.......... 01.2285 17.83 360088......... 01.2127 15.48 360172......... 01.3763 16.62 370036......... 01.0290 ......
340155....................... 01.3926 20.91 360012.......... 01.3020 17.61 360089......... 01.1680 16.92 360174......... 01.2365 19.24 370037......... 01.7236 17.83
340156....................... 00.8066 ....... 360013.......... 01.0836 16.71 360090......... 01.2316 17.90 360175......... 01.2401 17.61 370038......... 00.9187 12.01
340158....................... 01.1738 16.16 360014.......... 01.1219 17.57 360091......... 01.2648 18.90 360176......... 01.1559 15.53 370039......... 01.4573 17.22
340159....................... 01.1571 16.88 360016.......... 01.6012 17.81 360092......... 01.2659 17.85 360177......... 01.2581 16.30 370040......... 01.1051 10.89
340160....................... 01.0774 12.88 360017.......... 01.7592 19.82 360093......... 01.2188 16.66 360178......... 01.2276 15.58 370041......... 01.0285 13.52
340162....................... 01.2237 17.29 360018.......... 01.5445 18.51 360094......... 01.2950 20.27 360179......... 01.2916 19.01 370042......... 00.8575 10.56
340164....................... 01.4566 18.15 360019.......... 01.2857 18.22 360095......... 01.3340 16.68 360180......... 02.0922 22.07 370043......... 00.9719 12.91
340166....................... 01.4166 18.51 360020.......... 01.4313 20.05 360096......... 01.1097 16.20 360184......... 00.4913 17.11 370045......... 01.0983 10.20
340168....................... 00.5085 14.78 360021.......... 01.2770 18.04 360098......... 01.4006 18.00 360185......... 01.2493 17.09 370046......... 00.9827 09.22
340171....................... 01.1229 ....... 360024.......... 01.4310 17.76 360099......... 01.1130 16.91 360186......... 01.1727 15.04 370047......... 01.3245 15.40
350001....................... 01.0099 11.13 360025.......... 01.2355 17.66 360100......... 01.3239 15.63 360187......... 01.2787 16.00 370048......... 01.1876 13.46
350002....................... 01.7678 16.04 360026.......... 01.1897 15.59 360101......... 01.7334 19.71 360188......... 00.9998 14.77 370049......... 01.3566 15.60
350003....................... 01.1971 15.67 360027.......... 01.5255 19.06 360102......... 01.2713 19.68 360189......... 01.0092 15.40 370051......... 00.9627 13.31
350004....................... 01.9429 17.88 360028.......... 01.4563 15.28 360103......... 01.3290 18.70 360192......... 01.2404 19.28 370054......... 01.3878 14.79
350005....................... 01.0670 13.14 360029.......... 01.1611 16.41 360104......... 01.8950 20.28 360193......... 01.3104 16.77 370056......... 01.5609 15.41
350006....................... 01.3958 16.16 360030.......... 01.1326 14.82 360106......... 01.0509 13.89 360194......... 01.1180 16.14 370057......... 01.1711 15.05
350007....................... 00.9510 12.20 360031.......... 01.3534 18.42 360107......... 01.2373 16.98 360195......... 01.1319 17.72 370059......... 01.1178 13.53
350008....................... 01.0408 15.15 360032.......... 01.0876 16.18 360108......... 01.0371 15.08 360197......... 01.2030 16.76 370060......... 01.0787 12.88
350009....................... 01.1648 15.74 360034.......... 01.1698 13.30 360109......... 01.0970 17.43 360200......... 00.9989 13.48 370063......... 01.0947 13.12
350010....................... 01.1768 12.30 360035.......... 01.5734 19.90 360112......... 01.7594 21.61 360203......... 01.1502 15.55 370064......... 01.0006 10.14
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[[Page 27516]]
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
370065....................... 01.0475 14.76 370195.......... 00.9505 ....... 390004......... 01.3767 16.70 390080......... 01.2555 18.66 390167......... 01.2691 20.71
370071....................... 01.0381 10.18 380001.......... 01.3213 19.27 390005......... 01.0865 14.82 390081......... 01.3510 20.23 390168......... 01.1971 17.49
370072....................... 00.9034 11.67 380002.......... 01.2104 22.74 390006......... 01.7405 17.39 390083......... 01.2377 20.87 390169......... 01.2059 18.63
370076....................... 01.3228 12.42 380003.......... 01.1411 18.75 390007......... 01.1827 21.33 390084......... 01.2406 15.29 390170......... 01.8512 22.43
370077....................... 01.2244 16.30 380004.......... 01.6835 22.89 390008......... 01.1329 15.08 390086......... 01.1338 16.87 390173......... 01.1970 17.08
370078....................... 01.7096 14.58 380005.......... 01.1844 19.47 390009......... 01.6076 17.97 390088......... 01.3128 18.42 390174......... 01.7084 24.17
370079....................... 00.9596 11.98 380006.......... 01.3941 18.29 390010......... 01.1788 16.58 390090......... 01.7984 19.42 390176......... 01.1554 16.79
370080....................... 00.9895 11.12 380007.......... 01.5747 22.66 390011......... 01.2486 16.49 390091......... 01.1719 17.09 390178......... 01.2863 17.63
370082....................... 00.9026 12.48 380008.......... 01.0694 18.69 390012......... 01.1879 19.15 390093......... 01.1483 15.20 390179......... 01.2723 22.80
370083....................... 00.9519 10.95 380009.......... 01.8168 22.17 390013......... 01.2292 16.77 390095......... 01.1706 13.95 390180......... 01.5471 22.83
370084....................... 01.0346 08.88 380010.......... 01.0963 24.15 390014......... 01.6409 16.42 390096......... 01.2685 16.88 390181......... 01.0604 17.80
370085....................... 00.8099 12.94 380011.......... 01.0945 14.95 390015......... 01.1953 13.06 390097......... 01.3276 20.91 390183......... 01.1832 17.16
370086....................... 01.1956 09.89 380013.......... 01.2681 21.54 390016......... 01.2237 15.58 390098......... 01.7625 20.06 390184......... 01.1052 17.69
370089....................... 01.2826 14.01 380014.......... 01.4140 18.89 390017......... 01.1682 14.20 390100......... 01.6300 19.30 390185......... 01.2228 16.12
370091....................... 01.6822 16.13 380017.......... 01.7069 21.77 390018......... 01.2273 19.41 390101......... 01.1992 15.70 390189......... 01.0395 17.78
370092....................... 01.0705 12.73 380018.......... 01.8382 19.21 390019......... 01.1151 14.53 390102......... 01.3664 20.34 390191......... 01.0524 13.91
370093....................... 01.8611 18.67 380019.......... 01.2076 18.88 390022......... 01.3923 21.81 390103......... 01.0990 17.17 390192......... 01.1238 17.15
370094....................... 01.4135 16.67 380020.......... 01.4350 20.06 390023......... 01.2514 19.71 390104......... 01.0557 15.15 390193......... 01.1950 15.39
370095....................... 00.9154 11.62 380021.......... 01.2873 19.10 390024......... 00.8646 22.54 390106......... 01.0122 14.85 390194......... 01.1560 18.97
370097....................... 01.3691 18.65 380022.......... 01.1702 19.92 390025......... 00.6443 16.64 390107......... 01.2482 18.52 390195......... 01.8265 22.08
370099....................... 01.1663 13.22 380023.......... 01.2350 17.76 390026......... 01.2687 20.58 390108......... 01.4077 19.97 390196......... 01.4066 ......
370100....................... 01.0423 13.02 380025.......... 01.2670 21.81 390027......... 01.9708 23.48 390109......... 01.1523 14.44 390197......... 01.3091 18.40
370103....................... 00.9024 11.77 380026.......... 01.1899 16.87 390028......... 01.7871 18.54 390110......... 01.6465 17.36 390198......... 01.1942 15.21
370105....................... 02.0043 17.06 380027.......... 01.2587 20.25 390029......... 01.9395 18.73 390111......... 01.8583 26.22 390199......... 01.2016 14.89
370106....................... 01.5411 16.96 380029.......... 01.1474 17.29 390030......... 01.2365 16.29 390112......... 01.1488 12.16 390200......... 01.0147 14.67
370108....................... 01.0551 10.82 380031.......... 01.0329 15.92 390031......... 01.1587 16.93 390113......... 01.2113 16.04 390201......... 01.2666 18.75
370112....................... 01.0769 12.33 380033.......... 01.7783 22.97 390032......... 01.2498 17.80 390114......... 01.1217 21.07 390203......... 01.3102 20.45
370113....................... 01.1674 12.33 380035.......... 01.3580 18.58 390035......... 01.2774 17.24 390115......... 01.3154 21.40 390204......... 01.2596 20.05
370114....................... 01.6305 14.69 380036.......... 01.1305 17.27 390036......... 01.3337 17.63 390116......... 01.2237 19.91 390205......... 01.3479 22.42
370121....................... 01.1729 15.78 380037.......... 01.2063 18.24 390037......... 01.3426 18.07 390117......... 01.1636 15.65 390206......... 01.3349 19.91
370122....................... 01.1291 09.78 380038.......... 01.3425 21.15 390039......... 01.0948 15.60 390118......... 01.1524 16.29 390209......... 01.0438 15.48
370123....................... 01.2098 14.12 380039.......... 01.3082 18.89 390040......... 01.0024 12.71 390119......... 01.3475 17.17 390211......... 01.1929 16.47
370125....................... 01.0284 11.90 380040.......... 01.2507 19.23 390041......... 01.2475 16.82 390121......... 01.3363 18.95 390213......... 00.9476 14.55
370126....................... 00.9483 10.66 380042.......... 01.1550 18.06 390042......... 01.4374 20.74 390122......... 01.0719 16.06 390215......... 01.1565 20.69
370131....................... 01.0232 12.93 380047.......... 01.6960 19.84 390043......... 01.0988 15.65 390123......... 01.3041 20.58 390217......... 01.2781 17.92
370133....................... 01.1213 09.82 380048.......... 01.0936 13.92 390044......... 01.5993 18.80 390125......... 01.2255 15.08 390219......... 01.3149 18.57
370138....................... 01.1138 14.40 380050.......... 01.3349 16.37 390045......... 01.7321 17.35 390126......... 01.3266 20.07 390220......... 01.2126 19.33
370139....................... 01.0944 10.62 380051.......... 01.5217 19.13 390046......... 01.5446 18.49 390127......... 01.2319 20.26 390222......... 01.3083 20.42
370140....................... 01.0059 11.71 380052.......... 01.1764 16.70 390047......... 01.6845 18.24 390128......... 01.2014 17.96 390223......... 01.6376 23.15
370141....................... 01.3883 19.17 380055.......... 01.2275 23.88 390048......... 01.1857 16.26 390130......... 01.1480 16.62 390224......... 00.9314 13.04
370146....................... 01.0486 12.03 380056.......... 01.0753 15.78 390049......... 01.5514 19.82 390131......... 01.2704 16.06 390225......... 01.2124 15.42
370148....................... 01.6050 19.01 380060.......... 01.5375 21.51 390050......... 02.1389 21.60 390132......... 01.2425 20.25 390226......... 01.7861 23.22
370149....................... 01.2373 15.19 380061.......... 01.5190 22.00 390051......... 02.1828 24.98 390133......... 01.7790 20.57 390228......... 01.2071 18.67
370153....................... 01.0915 13.17 380062.......... 01.1039 15.07 390052......... 01.1846 16.68 390135......... 01.2913 19.73 390231......... 01.3122 21.89
370154....................... 01.0164 12.31 380063.......... 01.3354 21.48 390054......... 01.2245 14.56 390136......... 01.2338 15.66 390233......... 01.3268 16.71
370156....................... 01.1022 13.37 380064.......... 01.4398 18.47 390055......... 01.7751 21.82 390137......... 01.2962 17.80 390235......... 01.5635 23.94
370158....................... 01.0538 12.08 380065.......... 01.0680 19.24 390056......... 01.1222 15.73 390138......... 01.3365 17.41 390236......... 01.1643 15.90
370159....................... 01.3427 13.95 380066.......... 01.3162 17.60 390057......... 01.3263 18.94 390139......... 01.4984 23.50 390237......... 01.6149 20.17
370163....................... 00.8558 10.99 380068.......... 01.0655 19.31 390058......... 01.3239 17.46 390142......... 01.6716 22.64 390238......... 01.3009 16.12
370165....................... 01.0872 11.74 380069.......... 01.1328 17.51 390060......... 01.1432 16.68 390145......... 01.3596 18.64 390242......... 01.2772 18.69
370166....................... 01.0886 15.48 380070.......... 01.3924 21.21 390061......... 01.4426 20.47 390146......... 01.3088 16.19 390244......... 00.9339 13.32
370169....................... 01.1024 10.66 380071.......... 01.2894 18.06 390062......... 01.1400 15.76 390147......... 01.2505 19.22 390245......... 01.3465 23.15
370170....................... 00.9792 ....... 380072.......... 00.9714 14.15 390063......... 01.7324 19.20 390149......... 01.2579 19.59 390246......... 01.2349 15.91
370171....................... 01.0341 ....... 380075.......... 01.4281 20.90 390064......... 01.5561 16.25 390150......... 01.1065 17.50 390247......... 01.0497 17.22
370172....................... 00.8587 ....... 380078.......... 01.1638 16.95 390065......... 01.2903 18.85 390151......... 01.2927 18.26 390249......... 01.0291 10.81
370173....................... 01.2420 ....... 380081.......... 01.1568 17.66 390066......... 01.2933 17.15 390152......... 01.0351 17.07 390256......... 01.7792 23.51
370174....................... 00.9656 ....... 380082.......... 01.2906 20.35 390067......... 01.8083 18.03 390153......... 01.2473 21.93 390258......... 01.2502 19.78
370176....................... 01.1495 16.48 380083.......... 01.2487 18.93 390068......... 01.3245 18.13 390154......... 01.1877 13.93 390260......... 01.1823 15.95
370177....................... 00.9686 10.10 380084.......... 01.2127 20.61 390069......... 01.3242 19.23 390155......... 01.2985 20.06 390262......... 01.9798 17.25
370178....................... 01.0015 12.17 380087.......... 01.0083 12.30 390070......... 01.2898 19.49 390156......... 01.4337 22.61 390263......... 01.4331 18.66
370179....................... 00.8966 14.28 380088.......... 01.0059 15.71 390071......... 01.1154 13.36 390157......... 01.3427 17.97 390265......... 01.3123 17.72
370180....................... 01.0716 ....... 380089.......... 01.2909 21.87 390072......... 01.1133 15.76 390158......... 01.5891 ....... 390266......... 01.2098 16.69
370183....................... 01.0864 14.00 380090.......... 01.3011 24.41 390073......... 01.6002 18.94 390160......... 01.2031 17.67 390267......... 01.2930 18.93
370186....................... 01.0206 12.72 380091.......... 01.2113 23.79 390074......... 01.2369 16.26 390161......... 01.0981 14.87 390268......... 01.3884 19.94
370189....................... 00.9754 10.13 380897.......... 04.9268 ....... 390075......... 01.2410 15.92 390162......... 01.4238 19.03 390270......... 01.3090 15.89
370190....................... 01.5480 17.49 390001.......... 01.3578 18.16 390076......... 01.3094 20.45 390163......... 01.2248 16.55 390272......... 00.4549 ......
370192....................... 01.1656 ....... 390002.......... 01.3668 17.03 390078......... 01.0633 15.98 390164......... 01.9412 19.14 390277......... 00.5643 20.34
370194....................... 01.1343 ....... 390003.......... 01.2571 15.57 390079......... 01.7083 16.83 390166......... 01.1041 17.40 390278......... 00.7673 17.52
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 27517]]
Page 13 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
390279....................... 01.0726 09.45 420005.......... 01.2017 14.35 430013......... 01.2330 15.06 440029......... 01.2864 16.30 440148......... 01.1406 14.37
390281....................... 03.1739 ....... 420006.......... 01.2785 18.90 430014......... 01.2742 16.77 440030......... 01.1989 13.21 440149......... 01.1993 15.19
400001....................... 01.2170 08.68 420007.......... 01.5103 16.31 430015......... 01.1801 14.41 440031......... 00.9653 12.29 440150......... 01.2853 19.58
400002....................... 01.4586 10.39 420009.......... 01.2131 15.70 430016......... 01.8185 17.59 440032......... 01.0553 12.65 440151......... 01.3706 15.86
400003....................... 01.2378 07.14 420010.......... 01.1070 14.35 430018......... 00.9882 14.06 440033......... 01.0675 14.84 440152......... 01.5616 16.91
400004....................... 01.1516 07.34 420011.......... 01.0905 14.89 430022......... 00.9656 10.91 440034......... 01.5798 16.64 440153......... 01.2607 15.10
400005....................... 01.1122 06.10 420014.......... 01.1343 14.11 430023......... 00.9173 09.95 440035......... 01.3176 15.65 440156......... 01.5650 18.85
400006....................... 01.2005 08.16 420015.......... 01.3145 15.96 430024......... 00.9117 12.28 440039......... 01.6355 16.76 440157......... 01.0913 13.64
400007....................... 01.2599 07.55 420016.......... 01.0635 14.39 430026......... 01.0798 11.36 440040......... 00.9697 17.03 440159......... 01.2358 14.83
400009....................... 01.0253 07.68 420018.......... 01.7204 18.94 430027......... 01.8117 16.54 440041......... 01.0374 12.35 440161......... 01.6916 20.58
400010....................... 00.9067 07.94 420019.......... 01.2221 14.90 430028......... 01.0938 13.68 440046......... 01.3271 13.59 440166......... 01.4407 17.80
400011....................... 00.9999 08.65 420020.......... 01.3908 15.98 430029......... 00.9886 13.10 440047......... 00.9568 15.31 440168......... 01.0199 13.03
400012....................... 01.2156 07.09 420023.......... 01.4241 18.07 430031......... 00.9673 11.31 440048......... 01.7988 16.64 440173......... 01.5155 16.91
400013....................... 01.2969 08.96 420026.......... 01.9266 18.05 430033......... 01.0218 11.90 440049......... 01.6566 15.62 440174......... 00.9837 13.30
400014....................... 01.3613 07.51 420027.......... 01.3790 15.50 430034......... 01.0752 11.58 440050......... 01.2035 15.14 440175......... 01.2366 18.06
400015....................... 01.2211 10.88 420030.......... 01.2885 15.83 430036......... 01.0398 10.11 440051......... 00.9285 13.29 440176......... 01.2916 18.36
400016....................... 01.3614 10.48 420031.......... 00.9586 12.15 430037......... 00.9784 12.89 440052......... 01.2226 14.15 440178......... 01.1880 20.20
400017....................... 01.2405 06.27 420033.......... 01.2216 19.24 430038......... 01.0179 10.77 440053......... 01.3071 15.64 440180......... 01.1517 16.68
400018....................... 01.3516 09.35 420035.......... 00.7985 12.43 430039......... 01.0871 11.53 440054......... 01.2182 13.84 440181......... 01.0190 11.75
400019....................... 01.6737 09.48 420036.......... 01.2011 15.38 430040......... 00.9098 12.17 440056......... 01.0857 13.45 440182......... 00.9568 15.33
400021....................... 01.4421 07.62 420037.......... 01.2778 19.65 430041......... 00.9376 11.91 440057......... 01.0155 10.77 440183......... 01.5296 15.06
400022....................... 01.3098 09.79 420038.......... 01.2852 14.43 430042......... 00.9807 10.63 440058......... 01.3158 14.95 440184......... 01.3494 18.63
400024....................... 01.0265 08.62 420039.......... 01.1511 14.52 430043......... 01.1938 11.97 440059......... 01.3336 15.98 440185......... 01.1231 14.24
400026....................... 00.9430 05.90 420042.......... 01.2035 12.15 430044......... 00.9249 13.17 440060......... 01.1799 14.76 440186......... 01.1885 16.21
400027....................... 01.1317 08.32 420043.......... 01.1800 18.82 430047......... 01.1381 12.24 440061......... 01.2121 15.46 440187......... 01.1952 14.85
400028....................... 01.0328 07.14 420048.......... 01.1376 14.26 430048......... 01.2063 15.01 440063......... 01.6136 17.43 440189......... 01.4819 18.81
400029....................... 01.1287 06.64 420049.......... 01.1769 14.55 430049......... 00.9360 12.66 440064......... 01.1860 15.05 440192......... 01.1489 13.99
400031....................... 01.1446 08.00 420051.......... 01.5568 17.99 430051......... 01.0355 13.48 440065......... 01.2301 16.18 440193......... 01.2852 17.88
400032....................... 01.1257 07.75 420053.......... 01.1378 14.03 430054......... 01.0034 13.13 440067......... 01.1879 15.54 440194......... 01.4249 16.89
400044....................... 01.2430 09.09 420054.......... 01.3709 16.39 430056......... 00.8479 08.93 440068......... 01.2130 16.43 440196......... 00.9475 13.32
400048....................... 01.1320 07.91 420055.......... 01.0623 12.51 430057......... 00.9205 10.47 440069......... 01.1874 14.17 440197......... 01.4007 19.15
400061....................... 01.7050 13.68 420056.......... 01.1625 13.41 430060......... 01.1594 08.46 440070......... 01.1257 12.52 440200......... 01.1917 15.41
400079....................... 01.2488 08.95 420057.......... 01.1395 14.96 430062......... 00.8739 10.31 440071......... 01.3946 14.87 440203......... 00.9346 13.17
400087....................... 01.3761 08.90 420059.......... 00.9844 13.96 430064......... 01.1205 11.89 440072......... 01.5118 13.92 440205......... 01.0962 15.86
400094....................... 01.0405 07.41 420061.......... 01.1517 16.16 430065......... 00.9527 09.93 440073......... 01.3464 16.95 440206......... 01.0340 13.82
400098....................... 01.2435 07.17 420062.......... 01.4444 15.65 430066......... 00.9685 10.93 440078......... 01.0260 13.28 440208......... 02.0269 ......
400102....................... 01.1413 08.65 420064.......... 01.1161 13.45 430073......... 01.0814 ....... 440081......... 01.1575 15.31 450002......... 01.4623 19.35
400103....................... 01.3671 08.80 420065.......... 01.3051 16.72 430076......... 00.9768 09.41 440082......... 01.9905 20.54 450004......... 01.1684 12.38
400104....................... 01.3703 08.97 420066.......... 00.9099 14.40 430077......... 01.5832 16.53 440083......... 01.1099 10.96 450005......... 01.1503 13.79
400105....................... 01.1725 08.37 420067.......... 01.2333 16.24 430079......... 00.9628 11.47 440084......... 01.1544 11.41 450007......... 01.2442 13.73
400106....................... 01.2084 08.12 420068.......... 01.2885 16.08 430080......... 01.1317 08.89 440087......... 00.9572 14.44 450008......... 01.3624 14.96
400109....................... 01.5298 09.13 420069.......... 01.1002 13.71 430081......... 01.0452 ....... 440090......... 00.9308 13.29 450010......... 01.3415 15.37
400110....................... 01.1119 07.87 420070.......... 01.2639 15.05 430082......... 00.8001 ....... 440091......... 01.5472 16.53 450011......... 01.5000 17.43
400111....................... 01.1553 07.98 420071.......... 01.3110 16.13 430083......... 00.8672 ....... 440100......... 01.0273 12.82 450014......... 01.0699 13.84
400112....................... 01.2298 09.26 420072.......... 01.0735 10.64 430084......... 00.9280 ....... 440102......... 01.0695 12.26 450015......... 01.5543 14.96
400113....................... 01.2400 07.57 420073.......... 01.3095 18.10 430085......... 00.8385 ....... 440103......... 01.2284 17.24 450016......... 01.6256 17.57
400114....................... 01.0377 06.50 420074.......... 00.8992 11.72 430087......... 00.9105 09.29 440104......... 01.6509 17.68 450018......... 01.6091 21.75
400115....................... 01.0054 07.56 420075.......... 00.9719 12.66 440001......... 01.1227 12.18 440105......... 01.3723 16.69 450020......... 01.0171 15.47
400117....................... 01.1773 09.23 420078.......... 01.8088 18.59 440002......... 01.5965 15.80 440109......... 01.1308 12.28 450021......... 01.8117 21.11
400118....................... 01.1900 08.14 420079.......... 01.5669 16.94 440003......... 01.0714 15.23 440110......... 00.9687 16.06 450023......... 01.4846 15.80
400120....................... 01.3084 09.14 420080.......... 01.2589 19.18 440006......... 01.6500 17.60 440111......... 01.3613 18.00 450024......... 01.3672 16.45
400121....................... 01.0121 06.51 420082.......... 01.3946 19.13 440007......... 01.0148 11.83 440114......... 01.0474 12.68 450025......... 01.5058 16.27
400122....................... 01.0009 05.88 420083.......... 01.2042 18.36 440008......... 00.9878 13.50 440115......... 01.1172 14.66 450028......... 01.6335 17.17
400123....................... 01.1728 08.05 420084.......... 00.7413 13.56 440009......... 01.1753 13.22 440120......... 01.5385 16.14 450029......... 01.3991 12.98
400124....................... 02.6604 09.27 420085.......... 01.3970 16.86 440010......... 00.9235 08.75 440125......... 01.4408 16.09 450031......... 01.5830 18.72
410001....................... 01.3246 23.02 420086.......... 01.3613 16.90 440011......... 01.2901 16.28 440130......... 01.1687 14.16 450032......... 01.2715 13.63
410004....................... 01.3655 21.15 420087.......... 01.5946 16.53 440012......... 01.4699 17.72 440131......... 01.1317 13.44 450033......... 01.6308 16.84
410005....................... 01.3492 21.90 420088.......... 01.1349 15.05 440014......... 01.0615 09.06 440132......... 01.1116 14.01 450034......... 01.6445 16.28
410006....................... 01.2670 21.40 420089.......... 01.2336 19.40 440015......... 01.6051 16.42 440133......... 01.5494 17.78 450035......... 01.4519 18.91
410007....................... 01.6550 20.96 420091.......... 01.2147 13.16 440016......... 01.0116 11.35 440135......... 01.3062 14.03 450037......... 01.6279 17.69
410008....................... 01.1691 21.05 430004.......... 01.0955 17.25 440017......... 01.6136 18.42 440137......... 00.9770 12.14 450039......... 01.3345 18.70
410009....................... 01.2968 20.66 430005.......... 01.3167 14.06 440018......... 01.4675 16.10 440141......... 01.0771 13.59 450040......... 01.5518 17.75
410010....................... 01.0160 25.40 430007.......... 01.0540 12.52 440019......... 01.6253 19.06 440142......... 01.0311 10.75 450042......... 01.6646 15.75
410011....................... 01.2110 22.25 430008.......... 01.1248 14.01 440020......... 01.2392 15.43 440143......... 01.1020 17.21 450043......... 01.4473 20.40
410012....................... 01.7208 19.51 430009.......... 01.0939 12.21 440022......... 01.2040 13.72 440144......... 01.3327 18.35 450044......... 01.6182 20.04
410013....................... 01.3105 24.63 430010.......... 01.1273 09.23 440023......... 00.9963 11.58 440145......... 01.0439 10.99 450046......... 01.3724 14.67
420002....................... 01.3794 18.80 430011.......... 01.3139 14.33 440024......... 01.3302 16.61 440146......... 01.0036 12.98 450047......... 01.1155 13.43
420004....................... 01.8612 18.35 430012.......... 01.3055 14.97 440025......... 01.1317 13.01 440147......... 01.1079 17.06 450050......... 01.0582 16.00
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 27518]]
Page 14 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450051....................... 01.5923 18.22 450154.......... 01.2004 12.23 450296......... 01.3139 16.46 450484......... 01.4849 18.53 450651......... 01.8166 21.92
450052....................... 01.0171 13.13 450155.......... 01.0191 12.61 450297......... 01.0190 12.01 450488......... 01.2528 14.98 450652......... 00.9114 13.44
450053....................... 01.1479 13.11 450157.......... 01.0041 12.97 450299......... 01.3455 16.28 450489......... 00.9859 11.56 450653......... 01.2485 17.98
450054....................... 01.7181 21.32 450160.......... 00.9838 17.50 450303......... 00.9458 09.97 450497......... 01.1299 12.05 450654......... 01.0034 11.11
450055....................... 01.1238 12.92 450162.......... 01.1851 16.63 450306......... 01.0878 12.50 450498......... 01.2653 13.88 450656......... 01.4908 16.48
450056....................... 01.6174 18.26 450163.......... 01.0364 15.34 450307......... 00.9041 13.62 450508......... 01.5582 16.37 450658......... 00.9746 14.01
450058....................... 01.5774 14.76 450164.......... 01.0684 12.56 450309......... 01.0677 12.74 450514......... 01.2163 18.78 450659......... 01.5762 22.12
450059....................... 01.2421 13.21 450165.......... 00.9569 14.34 450315......... 01.1137 19.65 450517......... 01.0029 10.94 450660......... 01.5698 21.85
450060....................... 01.3622 22.17 450166.......... 00.9672 10.06 450320......... 01.3364 18.20 450518......... 01.5325 16.84 450661......... 01.1378 18.94
450063....................... 00.9758 11.51 450169.......... 00.9171 13.82 450321......... 00.9661 12.45 450523......... 01.5243 21.18 450662......... 01.6712 16.53
450064....................... 01.5083 15.34 450170.......... 00.9792 11.32 450322......... 00.7151 15.40 450530......... 01.4505 21.64 450665......... 00.9334 11.45
450065....................... 01.1393 14.75 450176.......... 01.2241 15.23 450324......... 01.6484 15.19 450534......... 00.9542 20.29 450666......... 01.2708 19.05
450068....................... 01.7951 20.31 450177.......... 01.0967 13.18 450325......... 01.2279 11.93 450535......... 01.2557 14.12 450668......... 01.5484 18.90
450070....................... 01.2671 15.46 450178.......... 01.0123 14.64 450327......... 00.9734 12.11 450537......... 01.3698 17.80 450669......... 01.2923 19.10
450072....................... 01.2351 18.19 450181.......... 01.0065 15.15 450330......... 01.2256 16.86 450538......... 01.3931 21.17 450670......... 01.2960 19.44
450073....................... 01.1202 12.84 450184.......... 01.5429 17.74 450334......... 01.0568 11.65 450539......... 01.2925 13.27 450672......... 01.6578 18.91
450076....................... 01.5802 ....... 450185.......... 01.1137 08.47 450337......... 01.2313 17.14 450544......... 01.4408 22.65 450673......... 01.1428 11.38
450078....................... 00.9949 11.17 450187.......... 01.2789 16.44 450340......... 01.3177 14.54 450545......... 01.2710 14.13 450674......... 01.0203 22.09
450079....................... 01.4395 19.03 450188.......... 01.0085 12.46 450341......... 01.0264 16.26 450546......... 01.8365 18.37 450675......... 01.5171 17.78
450080....................... 01.2966 15.79 450190.......... 01.1841 19.53 450346......... 01.3443 16.27 450547......... 01.1613 15.09 450677......... 01.4324 19.18
450081....................... 01.1087 12.87 450191.......... 01.0864 15.75 450347......... 01.1430 15.48 450550......... 00.9800 17.01 450678......... 01.4776 20.45
450082....................... 00.9627 12.75 450192.......... 01.2403 15.49 450348......... 00.9975 10.99 450551......... 01.1957 13.75 450681......... 03.0551 17.29
450083....................... 01.7142 17.21 450193.......... 01.8944 21.32 450351......... 01.1727 18.76 450558......... 01.7767 17.17 450683......... 01.3083 20.17
450085....................... 01.0903 14.38 450194.......... 01.2291 18.11 450352......... 01.1141 16.21 450559......... 00.9811 12.75 450684......... 01.2695 18.53
450087....................... 01.4141 19.35 450196.......... 01.5101 17.34 450353......... 01.3226 16.13 450561......... 01.6522 17.65 450686......... 01.5555 14.30
450090....................... 01.2144 12.40 450197.......... 01.0544 19.66 450355......... 01.1121 11.18 450563......... 01.2306 21.98 450688......... 01.2802 18.65
450092....................... 01.2129 13.12 450200.......... 01.3827 16.35 450358......... 02.0930 20.57 450565......... 01.2925 15.63 450690......... 01.4169 21.31
450094....................... 01.2531 19.39 450201.......... 01.0233 15.38 450362......... 01.1896 17.62 450570......... 01.0316 11.23 450691......... 01.1089 14.91
450096....................... 01.5315 19.25 450203.......... 01.1919 16.13 450369......... 01.0842 10.21 450571......... 01.4989 14.52 450694......... 01.2338 15.91
450097....................... 01.4577 18.33 450209.......... 01.5494 16.26 450370......... 01.1269 13.02 450573......... 01.0008 13.58 450696......... 01.6701 23.37
450098....................... 01.1683 13.75 450210.......... 01.1950 12.03 450371......... 01.1487 11.02 450574......... 00.9382 13.41 450697......... 01.5431 16.28
450099....................... 01.2816 17.70 450211.......... 01.3861 14.13 450372......... 01.2680 20.49 450575......... 01.0572 16.98 450698......... 00.9742 11.66
450101....................... 01.4848 15.03 450213.......... 01.5055 16.27 450373......... 01.1462 13.68 450578......... 00.9224 12.94 450700......... 00.9302 12.68
450102....................... 01.7093 21.87 450214.......... 01.3721 18.61 450374......... 00.9541 12.20 450580......... 01.1076 12.59 450702......... 01.6063 17.58
450104....................... 01.2182 13.74 450217.......... 01.0508 12.61 450376......... 01.5102 16.26 450583......... 01.0094 12.24 450703......... 01.5299 20.96
450107....................... 01.6171 18.75 450219.......... 01.1346 14.22 450378......... 01.0973 21.56 450584......... 01.2257 12.86 450704......... 01.3719 17.86
450108....................... 00.9967 14.49 450221.......... 01.0814 14.05 450379......... 01.5198 21.28 450586......... 00.9987 11.26 450705......... 01.0246 16.80
450109....................... 00.9911 15.36 450222.......... 01.6508 17.32 450381......... 01.0567 12.56 450587......... 01.2266 16.93 450706......... 01.2165 21.90
450110....................... 01.2522 19.34 450224.......... 01.3702 15.85 450388......... 01.7602 17.41 450591......... 01.1417 16.28 450709......... 01.2281 20.05
450111....................... 01.2466 18.63 450229.......... 01.5708 14.82 450389......... 01.2066 16.74 450596......... 01.3150 17.29 450711......... 01.6431 17.88
450112....................... 01.3508 13.87 450231.......... 01.5945 16.94 450393......... 01.3320 20.94 450597......... 01.0561 14.23 450712......... 00.7387 15.03
450113....................... 01.2359 16.99 450234.......... 00.9823 11.27 450395......... 01.0348 14.68 450603......... 00.8332 16.27 450713......... 01.4783 18.10
450118....................... 01.5629 20.94 450235.......... 01.0563 13.47 450399......... 00.9957 13.37 450604......... 01.3817 13.57 450715......... 01.4531 17.40
450119....................... 01.2958 16.37 450236.......... 01.0665 14.17 450400......... 01.1526 13.70 450605......... 01.4745 17.91 450716......... 01.2682 19.64
450121....................... 01.4393 18.70 450237.......... 01.5510 16.60 450403......... 01.3684 19.90 450609......... 00.8790 12.25 450717......... 01.3585 22.95
450123....................... 01.1554 17.47 450239.......... 01.1977 12.35 450411......... 00.9524 11.46 450610......... 01.4506 15.52 450718......... 01.2381 19.18
450124....................... 01.5864 19.48 450241.......... 01.0458 15.67 450417......... 01.0539 12.95 450614......... 01.0471 12.43 450723......... 01.3474 18.17
450126....................... 01.3845 11.95 450243.......... 00.8395 11.57 450418......... 01.3370 17.42 450615......... 01.0767 11.70 450724......... 01.2905 16.59
450128....................... 01.2434 14.78 450246.......... 00.9676 15.02 450419......... 01.2738 22.40 450617......... 01.2885 20.82 450725......... 00.9969 20.18
450130....................... 01.5025 15.17 450249.......... 00.9712 10.70 450422......... 00.8075 23.47 450620......... 01.0455 12.48 450726......... 00.8676 14.54
450131....................... 01.3707 19.58 450250.......... 00.9532 09.93 450423......... 01.4394 21.03 450623......... 01.1429 17.62 450727......... 00.9596 09.78
450132....................... 01.6610 16.45 450253.......... 01.3163 13.51 450424......... 01.2047 16.33 450626......... 01.0877 14.09 450728......... 00.9627 14.31
450133....................... 01.5384 16.49 450258.......... 01.0962 11.17 450429......... 01.1242 13.35 450628......... 00.9420 15.48 450730......... 01.3579 21.14
450135....................... 01.7273 21.81 450259.......... 01.2084 17.44 450431......... 01.6589 17.28 450630......... 01.6424 20.60 450733......... 01.3470 16.91
450137....................... 01.5099 24.28 450264.......... 00.8643 11.94 450438......... 01.1793 14.39 450631......... 01.7535 18.05 450735......... 00.8720 11.91
450140....................... 00.8414 16.46 450269.......... 01.1388 12.62 450446......... 00.8625 13.07 450632......... 01.0125 11.17 450742......... 01.3448 21.43
450142....................... 01.4366 19.50 450270.......... 01.1746 10.16 450447......... 01.3505 17.69 450633......... 01.5938 19.18 450743......... 01.4622 18.40
450143....................... 01.0982 12.23 450271.......... 01.2762 14.41 450450......... 01.0872 ....... 450634......... 01.6943 21.57 450746......... 01.0500 13.39
450144....................... 01.1175 16.23 450272.......... 01.2923 16.29 450451......... 01.1254 20.23 450637......... 01.3647 18.24 450747......... 01.3619 16.51
450145....................... 00.8692 12.46 450276.......... 01.0996 10.44 450457......... 01.7832 17.14 450638......... 01.5844 22.52 450749......... 01.0128 12.35
450146....................... 00.9881 16.53 450278.......... 00.8495 18.12 450460......... 01.0299 12.06 450639......... 01.4141 21.41 450750......... 01.0228 11.86
450147....................... 01.4175 17.66 450280.......... 01.5286 20.58 450462......... 01.8354 17.99 450641......... 01.0224 12.60 450751......... 01.3246 21.80
450148....................... 01.3079 19.02 450283.......... 01.0519 12.09 450464......... 00.9825 13.41 450643......... 01.2796 17.60 450754......... 00.8884 13.19
450149....................... 01.3501 19.33 450286.......... 01.0373 14.54 450465......... 01.3178 14.66 450644......... 01.4715 20.30 450755......... 01.1540 13.66
450150....................... 00.8919 13.62 450288.......... 01.2105 12.58 450467......... 00.9653 14.39 450646......... 01.6143 19.59 450757......... 00.9784 13.32
450151....................... 01.1057 13.27 450289.......... 01.4907 17.37 450469......... 01.3736 16.94 450647......... 02.0240 19.98 450758......... 01.2423 ......
450152....................... 01.2645 16.04 450292.......... 01.2051 20.15 450473......... 01.0047 17.83 450648......... 01.0382 11.36 450760......... 01.2068 16.97
450153....................... 01.5803 17.10 450293.......... 00.9746 13.55 450475......... 01.1363 14.13 450649......... 01.0756 14.64 450761......... 01.0642 09.63
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 27519]]
Page 15 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450763....................... 01.0163 15.68 460047.......... 01.7740 19.49 490067......... 01.2062 14.95 500029......... 00.9339 14.30 500141......... 01.3258 21.93
450766....................... 02.3234 14.24 460049.......... 01.9207 17.05 490069......... 01.3990 15.10 500030......... 01.4753 22.13 500143......... 00.7662 14.92
450769....................... 01.0378 13.28 460050.......... 01.3106 20.35 490071......... 01.4398 17.56 500031......... 01.2905 20.19 500146......... 01.0318 ......
450770....................... 00.9496 13.59 460051.......... 01.1901 ....... 490073......... 01.3538 21.49 500033......... 01.2047 18.05 510001......... 01.7139 17.08
450771....................... 01.9690 17.01 470001.......... 01.2043 17.11 490074......... 01.3343 16.00 500036......... 01.3185 19.11 510002......... 01.2708 16.31
450774....................... 00.9708 23.99 470003.......... 01.8136 17.82 490075......... 01.3332 16.62 500037......... 01.1216 17.63 510004......... 00.9183 12.62
450775....................... 01.1940 19.26 470004.......... 01.1118 14.18 490077......... 01.1636 16.87 500039......... 01.3772 21.32 510005......... 01.0028 13.71
450776....................... 00.9251 ....... 470005.......... 01.2608 18.71 490079......... 01.3187 14.30 500041......... 01.2872 22.09 510006......... 01.2565 17.08
450777....................... 01.0014 15.01 470006.......... 01.1898 17.05 490083......... 00.6451 14.63 500042......... 01.3735 20.95 510007......... 01.4707 17.81
450779....................... 01.3450 20.59 470008.......... 01.2516 15.41 490084......... 01.2535 15.96 500043......... 01.2939 16.56 510008......... 01.1226 15.33
450780....................... 01.6140 19.78 470010.......... 01.1804 18.58 490085......... 01.2071 13.36 500044......... 01.8920 20.56 510012......... 01.0670 14.26
450781....................... 01.4783 16.23 470011.......... 01.1610 19.30 490088......... 01.2024 13.97 500045......... 01.1167 20.65 510013......... 01.1365 15.10
450785....................... 01.0516 26.08 470012.......... 01.2651 17.52 490089......... 01.0748 14.37 500048......... 00.9122 16.01 510015......... 00.9706 12.51
450788....................... 01.4208 ....... 470013.......... 01.1682 18.28 490090......... 01.1783 14.25 500049......... 01.4708 19.34 510016......... 00.9917 11.27
450792....................... 01.3306 ....... 470015.......... 01.0806 16.29 490091......... 01.2045 20.14 500050......... 01.4079 20.41 510018......... 01.1351 14.40
450793....................... 01.6623 ....... 470018.......... 01.1930 17.37 490092......... 01.2038 14.32 500051......... 01.6292 22.71 510020......... 01.0494 10.16
450794....................... 01.4602 ....... 470020.......... 00.9884 14.50 490093......... 01.2927 15.31 500052......... 01.2781 ....... 510022......... 01.7998 19.52
450795....................... 00.8520 ....... 470023.......... 01.2947 17.20 490094......... 01.0700 14.57 500053......... 01.2686 20.10 510023......... 01.1454 15.14
450797....................... 00.6382 ....... 470024.......... 01.1136 17.08 490095......... 01.4745 16.13 500054......... 01.8788 20.41 510024......... 01.4093 17.94
450798....................... 00.8871 ....... 490001.......... 01.0799 19.41 490097......... 01.1333 13.69 500055......... 01.0886 20.32 510026......... 00.9392 12.19
450799....................... 01.3895 ....... 490002.......... 01.0625 13.61 490098......... 01.3132 11.69 500057......... 01.3490 16.24 510027......... 00.9669 13.86
450800....................... 01.3919 ....... 490003.......... 00.6018 17.55 490099......... 00.9348 15.29 500058......... 01.5095 19.82 510028......... 01.0731 14.90
450801....................... 01.4818 ....... 490004.......... 01.2303 16.67 490100......... 01.3757 16.69 500059......... 01.1588 20.02 510029......... 01.2953 16.69
450802....................... 01.2487 ....... 490005.......... 01.5364 16.10 490101......... 01.1933 23.64 500060......... 01.4869 20.70 510030......... 01.0968 14.87
450803....................... 00.8537 ....... 490006.......... 01.1569 13.27 490104......... 00.9110 14.46 500061......... 00.9842 17.95 510031......... 01.3367 16.27
450804....................... 01.5293 ....... 490007.......... 02.0310 17.19 490105......... 00.7427 16.55 500062......... 01.0856 17.16 510033......... 01.2624 14.42
450805....................... 01.1693 ....... 490009.......... 01.8204 18.08 490106......... 00.9047 14.86 500064......... 01.5371 21.69 510035......... 01.1467 16.46
450807....................... 00.9104 ....... 490010.......... 01.0912 17.08 490107......... 01.3155 22.64 500065......... 01.3049 17.67 510036......... 01.0129 09.34
450809....................... 01.6570 ....... 490011.......... 01.4170 17.03 490108......... 00.8737 13.78 500068......... 01.0186 17.17 510038......... 01.1610 13.71
450897....................... 04.8548 ....... 490012.......... 01.1990 15.55 490109......... 00.9185 14.09 500069......... 01.1665 18.62 510039......... 01.3580 15.02
460001....................... 01.7866 19.82 490013.......... 01.2514 14.82 490110......... 01.3986 15.90 500071......... 01.3666 19.46 510043......... 00.9310 11.33
460003....................... 01.7210 18.38 490014.......... 01.3584 21.04 490111......... 01.2348 16.79 500072......... 01.1952 21.19 510046......... 01.2605 15.26
460004....................... 01.7712 20.68 490015.......... 01.4630 17.30 490112......... 01.7326 19.07 500073......... 01.0859 16.85 510047......... 01.2074 17.37
460005....................... 01.5499 18.80 490017.......... 01.3623 16.44 490113......... 01.3003 20.96 500074......... 01.1671 14.80 510048......... 01.0733 17.39
460006....................... 01.4322 18.21 490018.......... 01.2580 16.83 490114......... 01.0988 15.00 500075......... 03.7376 20.25 510050......... 01.4642 15.34
460007....................... 01.5450 19.27 490019.......... 01.2006 15.60 490115......... 01.2451 14.25 500077......... 01.3913 21.63 510053......... 01.0396 13.50
460008....................... 01.3609 16.02 490020.......... 01.1565 14.16 490116......... 01.2251 15.61 500079......... 01.4055 19.87 510055......... 01.2246 19.41
460009....................... 01.8852 18.11 490021.......... 01.1505 17.11 490117......... 01.1729 13.62 500080......... 00.8427 11.56 510058......... 01.2002 16.23
460010....................... 01.9161 20.15 490022.......... 01.4063 17.59 490118......... 01.7642 21.32 500084......... 01.1439 20.05 510059......... 01.2290 13.65
460011....................... 01.3884 16.16 490023.......... 01.2234 17.03 490119......... 01.3467 16.41 500085......... 01.0619 17.19 510060......... 01.1538 15.36
460013....................... 01.5056 18.54 490024.......... 01.7803 17.06 490120......... 01.3270 16.88 500086......... 01.4244 18.48 510061......... 01.0749 12.59
460014....................... 01.0358 15.38 490027.......... 01.1310 13.11 490122......... 01.5152 20.86 500088......... 01.3586 22.86 510062......... 01.1797 15.38
460015....................... 01.2592 19.75 490028.......... 01.3516 18.42 490123......... 01.1414 14.80 500089......... 00.9469 13.99 510063......... 01.0126 10.63
460016....................... 00.8970 13.58 490030.......... 01.1033 11.16 490124......... 01.1521 16.99 500090......... 01.1042 12.60 510065......... 01.0089 12.04
460017....................... 01.4549 16.52 490031.......... 01.1369 12.61 490126......... 01.3837 14.72 500092......... 01.0798 15.65 510066......... 01.1288 12.02
460018....................... 00.9760 13.59 490032.......... 01.7249 19.08 490127......... 01.0179 14.44 500094......... 00.9177 15.53 510067......... 01.2496 15.91
460019....................... 01.1515 12.90 490033.......... 01.1854 15.21 490130......... 01.3118 16.58 500096......... 01.0950 17.13 510068......... 01.1196 14.01
460020....................... 01.0589 14.21 490035.......... 01.2179 09.64 490131......... 01.0427 14.06 500097......... 01.1371 16.12 510070......... 01.2210 16.05
460021....................... 01.3873 19.20 490037.......... 01.1278 13.27 500001......... 01.3342 20.92 500098......... 00.9192 13.66 510071......... 01.2767 14.49
460022....................... 00.9374 19.41 490038.......... 01.2195 12.54 500002......... 01.4828 18.75 500101......... 01.0080 17.84 510072......... 01.0650 13.50
460023....................... 01.1831 20.75 490040.......... 01.4100 ....... 500003......... 01.4073 21.28 500102......... 00.9391 18.43 510077......... 01.1079 14.36
460024....................... 00.8662 13.51 490041.......... 01.3633 16.88 500005......... 01.8398 22.52 500104......... 01.2622 18.71 510080......... 01.1530 09.35
460025....................... 00.8105 12.63 490042.......... 01.3475 15.18 500007......... 01.4207 20.14 500106......... 00.9247 15.53 510081......... 01.0320 13.19
460026....................... 01.0881 16.98 490043.......... 01.3704 16.74 500008......... 01.8411 22.88 500107......... 01.1321 15.58 510082......... 01.0578 12.08
460027....................... 00.9430 18.61 490044.......... 01.3658 16.65 500009......... 01.2857 21.07 500108......... 01.6669 21.40 510084......... 00.9741 12.87
460029....................... 01.0255 15.71 490045.......... 01.1319 18.60 500011......... 01.3718 21.44 500110......... 01.2887 18.75 510085......... 01.2422 17.99
460030....................... 01.2141 15.78 490046.......... 01.4645 17.24 500012......... 01.5217 20.94 500118......... 01.1240 20.88 510086......... 01.0448 15.65
460032....................... 01.0120 19.00 490047.......... 01.0663 16.34 500014......... 01.5715 22.36 500119......... 01.3333 20.48 520002......... 01.2873 17.24
460033....................... 00.9450 18.22 490048.......... 01.4906 17.53 500015......... 01.3714 20.92 500122......... 01.1925 20.27 520003......... 01.1635 15.19
460035....................... 00.9610 10.93 490050.......... 01.4363 20.06 500016......... 01.4877 22.76 500123......... 00.8543 14.78 520004......... 01.1581 16.53
460036....................... 00.9397 19.41 490052.......... 01.6013 15.06 500019......... 01.3295 19.82 500124......... 01.3292 22.39 520006......... 01.0583 18.05
460037....................... 01.0502 15.92 490053.......... 01.2501 14.14 500021......... 01.5380 20.77 500125......... 00.9834 10.72 520007......... 01.2469 14.14
460039....................... 01.0976 21.08 490054.......... 01.1101 13.91 500023......... 01.1763 19.09 500129......... 01.7339 22.41 520008......... 01.5546 20.54
460041....................... 01.2179 18.29 490057.......... 01.5486 17.02 500024......... 01.6324 21.06 500132......... 01.0006 19.79 520009......... 01.5961 16.88
460042....................... 01.4657 16.14 490059.......... 01.5727 18.24 500025......... 01.8715 21.69 500134......... 00.7903 15.75 520010......... 01.1768 19.39
460043....................... 00.9888 20.44 490060.......... 01.0661 16.72 500026......... 01.4324 22.42 500137......... 00.7110 19.99 520011......... 01.2031 16.46
460044....................... 01.2018 19.41 490063.......... 01.6611 22.34 500027......... 01.5334 23.68 500138......... 03.4209 ....... 520013......... 01.2909 17.88
460046....................... 00.7432 10.23 490066.......... 01.2178 17.42 500028......... 01.0839 14.76 500139......... 01.4763 21.33 520014......... 01.2083 15.55
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 27520]]
Page 16 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
520015....................... 01.1174 16.65 520107.......... 01.2599 17.46 530026......... 01.0473 14.63
520016....................... 01.0872 12.75 520109.......... 00.9937 17.25 530027......... 00.8416 09.56
520017....................... 01.1927 16.87 520110.......... 01.1756 16.47 530029......... 00.9590 13.49
520018....................... 01.0801 15.88 520111.......... 00.9841 14.44 530031......... 00.8745 10.95
520019....................... 01.2873 16.65 520112.......... 01.0805 18.15 530032......... 01.1558 17.33
520021....................... 01.3538 19.16 520113.......... 01.1645 17.80
520024....................... 01.0377 13.33 520114.......... 01.1037 12.61
520025....................... 01.1242 15.19 520115.......... 01.3222 15.89
520026....................... 01.1051 17.48 520116.......... 01.2576 17.66
520027....................... 01.2244 19.22 520117.......... 01.0303 15.40
520028....................... 01.3261 17.60 520118.......... 00.9469 10.95
520029....................... 00.9657 16.70 520120.......... 00.8647 11.95
520030....................... 01.6772 20.19 520121.......... 00.9763 14.18
520031....................... 01.1054 16.11 520122.......... 00.9894 13.96
520032....................... 01.1683 14.56 520123.......... 01.1427 16.55
520033....................... 01.1820 15.91 520124.......... 01.1255 14.34
520034....................... 01.1271 17.17 520130.......... 01.0776 12.60
520035....................... 01.2587 14.67 520131.......... 01.0620 15.82
520037....................... 01.6518 18.23 520132.......... 01.1878 14.31
520038....................... 01.4916 17.14 520134.......... 01.0269 15.14
520039....................... 00.9998 16.24 520135.......... 00.9427 13.84
520040....................... 01.4327 20.05 520136.......... 01.4778 18.87
520041....................... 01.1487 14.54 520138.......... 01.8773 18.18
520042....................... 01.0742 16.25 520139.......... 01.2893 18.50
520044....................... 01.3803 16.09 520140.......... 01.6143 19.31
520045....................... 01.6794 17.97 520141.......... 01.1223 15.63
520047....................... 01.0211 14.50 520142.......... 00.9152 12.48
520048....................... 01.4410 17.67 520144.......... 01.0302 16.10
520049....................... 01.9925 17.97 520145.......... 00.9155 16.57
520051....................... 02.0296 19.41 520146.......... 01.0749 13.71
520053....................... 01.1007 14.78 520148.......... 01.1668 15.34
520054....................... 01.0919 16.40 520149.......... 00.9581 13.31
520056....................... 01.3164 17.77 520151.......... 01.0803 14.43
520057....................... 01.1308 16.08 520152.......... 01.1177 16.38
520058....................... 01.0511 17.87 520153.......... 00.9775 13.19
520059....................... 01.3130 18.17 520154.......... 01.1520 16.15
520060....................... 01.2970 15.15 520156.......... 01.1216 16.37
520062....................... 01.2707 16.18 520157.......... 00.9447 13.70
520063....................... 01.2571 17.61 520159.......... 00.9412 16.25
520064....................... 01.7132 18.60 520160.......... 01.7643 17.77
520066....................... 01.4169 17.73 520161.......... 01.0283 14.76
520068....................... 00.8891 15.82 520170.......... 01.2367 18.51
520069....................... 01.1915 16.75 520171.......... 00.9904 13.69
520070....................... 01.6012 16.93 520173.......... 01.1609 17.36
520071....................... 01.1175 17.71 520174.......... 01.3641 20.57
520074....................... 01.1086 14.96 520177.......... 01.6458 20.33
520075....................... 01.4753 17.44 520178.......... 01.0634 14.61
520076....................... 01.1296 14.40 520186.......... 02.5906 .......
520077....................... 01.0286 14.50 530002.......... 01.1932 18.07
520078....................... 01.5021 17.89 530003.......... 00.9310 12.59
520082....................... 01.3454 15.25 530004.......... 01.0270 13.17
520083....................... 01.5871 21.59 530005.......... 01.1389 13.19
520084....................... 01.0883 15.73 530006.......... 01.1268 16.83
520087....................... 01.6162 17.16 530007.......... 01.0516 11.52
520088....................... 01.2469 17.56 530008.......... 01.2810 17.75
520089....................... 01.5230 18.79 530009.......... 00.9688 20.60
520090....................... 01.2710 16.16 530010.......... 01.2195 16.30
520091....................... 01.3709 17.25 530011.......... 01.0899 15.27
520092....................... 01.1124 15.11 530012.......... 01.5874 17.25
520094....................... 01.0158 16.07 530014.......... 01.3289 15.01
520095....................... 01.3510 18.56 530015.......... 01.1500 19.22
520096....................... 01.4979 17.78 530016.......... 01.2060 11.87
520097....................... 01.3308 17.90 530017.......... 01.0038 16.09
520098....................... 01.7143 19.40 530018.......... 01.0645 14.57
520100....................... 01.2350 15.91 530019.......... 00.9449 14.32
520101....................... 01.0947 15.75 530022.......... 01.1147 15.94
520102....................... 01.2141 19.00 530023.......... 00.8514 17.76
520103....................... 01.3242 17.70 530025.......... 01.3686 18.12
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Case mix indexes do not include discharges from PPS-exempt units. Case mix indexes include cases received in HCFA central office through December 1995.
[[Page 27521]]
Table 4a.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
------------------------------------------------------------------------
Urban area (constituent counties or county Wage
equivalents) index GAF
------------------------------------------------------------------------
0040 Abilene, TX................................... 0.8055 0.8623
Taylor, TX
0060 Aguadilla, PR................................. 0.4430 0.5726
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 0.9875 0.9914
Portage, OH
Summit, OH
0120 Albany, GA.................................... 0.8353 0.8841
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY................... 0.8510 0.8954
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM............................... 0.9390 0.9578
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.8213 0.8739
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 1.0014 1.0160
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9531 0.9676
Blair, PA
0320 Amarillo, TX.................................. 0.8557 0.8988
Potter, TX
Randall, TX
0380 Anchorage, AK................................. 1.3285 1.3104
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1688 1.1218
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.7848 0.8471
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.8910 0.9240
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR................................... 0.4631 0.5903
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.9365 0.9561
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.9259 0.9771
Clarke, GA
Madison, GA
Oconee, GA
0520 *Atlanta, GA.................................. 1.0089 1.0363
Barrow, GA
Bartow, GA
Carroll, GA
Cherokee, GA
Clayton, GA
Cobb, GA
Coweta, GA
DeKalb, GA
Douglas, GA
Fayette, GA
Forsyth, GA
Fulton, GA
Gwinnett, GA
Henry, GA
Newton, GA
Paulding, GA
Pickens, GA
Rockdale, GA
Spalding, GA
Walton, GA
0560 Atlantic-Cape May, NJ......................... 1.1102 1.0742
Atlantic, NJ
Cape May, NJ
0600 Augusta-Aiken, GA-SC.......................... 0.8849 0.9197
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX......................... 0.9252 0.9482
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA............................... 1.0202 1.0168
Kern, CA
0720 *Baltimore, MD................................ 0.9820 1.0173
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.................................... 0.9412 0.9594
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.3682 1.2395
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8442 0.8905
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8578 0.9003
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1342 1.0901
Whatcom, WA
0870 Benton Harbor, MI............................. 0.8553 0.8985
Berrien, MI
0875 *Bergen-Passaic, NJ........................... 1.1717 1.1146
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 0.8903 0.9235
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8573 0.8999
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY................................ 0.8842 0.9192
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.9047 0.9337
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.7976 0.8565
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.8619 0.9303
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.8921 0.9248
McLean, IL
1080 Boise City, ID................................ 0.9269 0.9493
Ada, ID
Canyon, ID
1123 *Boston-Worcester-Lawrence-Lowell-Brockton, MA-
NH................................................. 1.1639 1.1428
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125 Boulder-Longmont, CO.......................... 0.9383 0.9573
Boulder, CO
1145 Brazoria, TX.................................. 0.8865 0.9208
Brazoria, TX
1150 Bremerton, WA................................. 1.0926 1.0625
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.8561 0.8991
Cameron, TX
1260 Bryan-College Station, TX..................... 0.8760 0.9133
Brazos, TX
1280 *Buffalo-Niagara Falls, NY.................... 0.9123 0.9673
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 0.9126 0.9393
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.................................... 0.4661 0.5929
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
[[Page 27522]]
1320 Canton-Massillon, OH.......................... 0.8667 0.9067
Carroll, OH
Stark, OH
1350 Casper, WY.................................... 0.8841 0.9191
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.8477 0.8930
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.9413 0.9594
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.8984 0.9293
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9547 0.9688
Kanawha, WV
Putnam, WV
1520 *Charlotte-Gastonia-Rock Hill, NC-SC.......... 0.9631 1.0038
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 0.9175 0.9427
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.8867 0.9210
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY.................................. 0.7695 0.8357
Laramie, WY
1600 *Chicago, IL.................................. 1.0756 1.0827
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................ 1.0441 1.0300
Butte, CA
1640 *Cincinnati, OH-KY-IN......................... 0.9477 0.9928
Dearborn, IN
Ohio, IN
Boone, KY
Campbell, KY
Gallatin, KY
Grant, KY
Kenton, KY
Pendleton, KY
Brown, OH
Clermont, OH
Hamilton, OH
Warren, OH
1660 Clarksville-Hopkinsville, TN-KY............... 0.7733 0.8386
Christian, KY
Montgomery, TN
1680 *Cleveland-Lorain-Elyria, OH.................. 0.9908 1.0235
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9456 0.9624
El Paso, CO
1740 Columbia, MO.................................. 0.8919 0.9246
Boone, MO
1760 Columbia, SC.................................. 0.9178 0.9430
Lexington, SC
Richland, SC
1800 Columbus, GA-AL............................... 0.7655 0.8328
Russell, AL
Chattanoochee, GA
Harris, GA
Muscogee, GA
1840 *Columbus, OH................................. 0.9699 1.0087
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.8641 0.9048
Nueces, TX
San Patricio, TX
1900 Cumberland, MD-WV............................. 0.8613 0.9028
Allegany, MD
Mineral, WV
1920 *Dallas, TX................................... 0.9530 0.9966
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.8516 0.8958
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8407 0.8880
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9582 0.9858
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL............................. 0.8891 0.9296
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.8403 0.8877
Lawrence, AL
Morgan, AL
2040 Decatur, IL................................... 0.7866 0.8484
Macon, IL
2080 *Denver, CO................................... 1.0291 1.0504
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8772 0.9142
Dallas, IA
Polk, IA
Warren, IA
2160 *Detroit, MI.................................. 1.0748 1.0822
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.7758 0.8404
Dale, AL
Houston, AL
2190 Dover, DE..................................... 0.9017 0.9595
Kent, DE
2200 Dubuque, IA................................... 0.8149 0.8692
Dubuque, IA
2240 Duluth-Superior, MN-WI........................ 0.9437 0.9611
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY........................... 1.0604 1.0488
Dutchess, NY
2290 Eau Claire, WI................................ 0.8698 0.9089
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX................................... 0.9486 0.9645
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.8820 0.9176
Elkhart, IN
2335 Elmira, NY.................................... 0.8436 0.8901
Chemung, NY
2340 Enid, OK...................................... 0.7879 0.8494
Garfield, OK
2360 Erie, PA...................................... 0.9137 0.9401
Erie, PA
2400 Eugene-Springfield, OR........................ 1.1503 1.1006
Lane, OR
2440 Evansville-Henderson, IN-KY................... 0.8990 0.9297
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN......................... 0.9010 0.9311
[[Page 27523]]
Clay, MN
Cass, ND
2560 Fayetteville, NC.............................. 0.9025 0.9322
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.7236 0.8013
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 0.9039 0.9331
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.1273 1.0964
Genesee, MI
2650 Florence, AL.................................. 0.8157 0.8698
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8614 0.9029
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0628 1.0426
Larimer, CO
2680 *Ft. Lauderdale, FL........................... 1.0968 1.0973
Broward, FL
2700 Fort Myers-Cape Coral, FL..................... 0.9093 0.9370
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 1.0192 1.0131
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.7885 0.8498
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL......................... 0.9186 0.9435
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.8819 0.9175
Adams, IN
Allen, IN
DeKalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 *Forth Worth-Arlington, TX.................... 1.0095 1.0367
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 1.1202 1.0808
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8901 0.9234
Etowah, AL
2900 Gainesville, FL............................... 0.9455 0.9623
Alachua, FL
2920 Galveston-Texas City, TX...................... 1.1022 1.0796
Galveston, TX
2960 Gary, IN...................................... 0.9176 0.9428
Lake, IN
Porter, IN
2975 Glens Falls, NY............................... 0.8560 0.8990
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8412 0.8883
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.9228 0.9465
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.8847 0.9195
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI............. 1.0088 1.0060
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 0.9007 0.9309
Cascade, MT
3060 Greeley, CO................................... 0.9712 0.9802
Weld, CO
3080 Green Bay, WI................................. 0.9387 0.9576
Brown, WI
3120 *Greensboro-Winston-Salem-High Point, NC...... 0.9327 0.9820
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9098 0.9373
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.8947 0.9266
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD................................ 0.9195 0.9441
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.9515 0.9665
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 1.0181 1.0124
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 *Hartford, CT................................. 1.2395 1.1931
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS............................... 0.7269 0.8038
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.7945 0.8542
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1487 1.1776
Honolulu, HI
3350 Houma, LA..................................... 0.7843 0.8518
Lafourche, LA
Terrebonne, LA
3360 *Houston, TX.................................. 0.9790 1.0151
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9194 0.9441
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8145 0.8689
Limestone, AL
Madison, AL
3480 *Indianapolis, IN............................. 0.9950 1.0265
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9382 0.9573
Johnson, IA
3520 Jackson, MI................................... 0.9066 0.9351
Jackson, MI
3560 Jackson, MS................................... 0.7906 0.8514
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 0.8340 0.8831
Madison, TN
3605 Jacksonville, FL.............................. 0.9018 0.9317
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC.............................. 0.7071 0.7887
Onslow, NC
3610 Jamestown, NY................................. 0.7679 0.8346
Chautaqua, NY
3620 Janesville-Beloit, WI......................... 0.8664 0.9065
Rock, WI
3640 Jersey City, NJ............................... 1.1408 1.1236
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.8921 0.9248
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
[[Page 27524]]
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA................................. 0.8417 0.8887
Cambria, PA
Somerset, PA
3710 Joplin, MO.................................... 0.7409 0.8144
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 1.0565 1.0384
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.8998 0.9582
Kankakee, IL
3760 *Kansas City, KS-MO........................... 0.9522 0.9960
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800 Kenosha, WI................................... 0.9166 0.9421
Kenosha, WI
3810 Killeen-Temple, TX............................ 1.0415 1.0282
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.8520 0.8961
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.8609 0.9025
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN.............................. 0.8638 0.9046
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8183 0.8717
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.8824 0.9179
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA.............................. 0.8052 0.8621
Calcasieu, LA
3980 Lakeland-Winter Haven, FL..................... 0.8677 0.9074
Polk, FL
4000 Lancaster, PA................................. 0.9605 0.9786
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 1.0016 1.0011
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.................................... 0.7092 0.7903
Webb, TX
4100 Las Cruces, NM................................ 0.8516 0.8958
Dona Ana, NM
4120 *Las Vegas, NV-AZ............................. 1.0894 1.0922
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.8616 0.9301
Douglas, KS
4200 Lawton, OK.................................... 0.8339 0.8830
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.9431 0.9607
Androscoggin, ME
4280 Lexington, KY................................. 0.8387 0.8865
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.8752 0.9128
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 0.9193 0.9440
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8616 0.9030
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX......................... 0.8633 0.9042
Gregg, TX
Harrison, TX
Upshur, TX
4480 *Los Angeles-Long Beach, CA................... 1.2396 1.1932
Los Angeles, CA
4520 Louisville, KY-IN............................. 0.9445 0.9617
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8525 0.8965
Lubbock, TX
4640 Lynchburg, VA................................. 0.8036 0.8609
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.8836 0.9187
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 1.0048 1.0033
Dane, WI
4800 Mansfield, OH................................. 0.8543 0.8978
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4186 0.5508
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8502 0.8948
Hidalgo, TX
4890 Medford-Ashland, OR........................... 1.0213 1.0145
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.9089 0.9507
Brevard, FL
4920 *Memphis, TN-AR-MS............................ 0.8185 0.8980
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.................................... 1.0684 1.0463
Merced, CA
5000 *Miami, FL.................................... 0.9240 0.9757
Dade, FL
5015 *Middlesex-Somerset-Hunterdon, NJ............. 1.0777 1.0842
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 *Milwaukee-Waukesha, WI....................... 0.9667 1.0064
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 *Minneapolis-St. Paul, MN-WI.................. 1.0785 1.0847
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5160 Mobile, AL.................................... 0.7999 0.8582
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0135 1.0092
Stanislaus, CA
5190 *Monmouth-Ocean, NJ........................... 1.0842 1.0569
Monmouth, NJ
[[Page 27525]]
Ocean, NJ
5200 Monroe, LA.................................... 0.8234 0.8754
Ouachita, LA
5240 Montgomery, AL................................ 0.7949 0.8545
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.................................... 0.9736 1.0113
Delaware, IN
5330 Myrtle Beach, SC.............................. 0.7798 0.8434
Horry, SC
5345 Naples, FL.................................... 1.0222 1.0151
Collier, FL
5360 *Nashville, TN................................ 0.9065 0.9630
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 *Nassau-Suffolk, NY........................... 1.2852 1.2231
Nassau, NY
Suffolk, NY
5483 *New Haven-Bridgeport-Stamford-Waterbury-..... 1.2778 1.2183
Danbury, CT
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT........................ 1.2345 1.1898
New London, CT
5560 *New Orleans, LA.............................. 0.9434 0.9897
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 *New York, NY................................. 1.4041 1.2995
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 *Newark, NJ................................... 1.1057 1.1034
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.0829 1.0561
Orange, NY
Pike, PA
5720 *Norfolk-Virginia Beach-Newport News, VA-NC... 0.8326 0.9086
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
York, VA
5775 *Oakland, CA.................................. 1.5113 1.3666
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.8999 0.9303
Marion, FL
5800 Odessa-Midland, TX............................ 0.8552 0.8984
Ector, TX
Midland, TX
5880 *Oklahoma City, OK............................ 0.8463 0.9188
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA................................... 1.0713 1.0483
Thurston, WA
5920 Omaha, NE-IA................................. 0.9425 0.9603
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 *Orange County, CA............................ 1.1929 1.1622
Orange, CA
5960 *Orlando, FL.................................. 0.9491 0.9938
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY................................. 0.7578 0.8270
Daviess, KY
6015 Panama City, FL............................... 0.8080 0.8642
Bay, FL
6020 Parkersburg-Marietta, WV-OH................... 0.7895 0.8506
Washington, OH
Wood, WV
6080 Pensacola, FL................................. 0.8212 0.8738
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL.............................. 0.8923 0.9249
Peoria, IL
Tazewell, IL
Woodford, IL
6160 *Philadelphia, PA-NJ.......................... 1.1197 1.1129
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 *Phoenix-Mesa, AZ............................. 0.9832 1.0181
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.7904 0.8512
Jefferson, AR
6280 *Pittsburgh, PA............................... 0.9726 1.0106
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA................................ 1.0570 1.0387
Berkshire, MA
6360 Ponce, PR..................................... 0.4500 0.5788
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9615 0.9735
Cumberland, ME
Sagadahoc, ME
York, ME
6440 *Portland-Vancouver, OR-WA.................... 1.1267 1.1177
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 Providence-Warwick-Pawtucket, RI.............. 1.1116 1.0751
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 1.0139 1.0095
Utah, UT
6560 Pueblo, CO.................................... 0.8302 0.8804
Pueblo, CO
6580 Punta Gorda, FL............................... 0.8284 0.8790
Charlotte, FL
6600 Racine, WI.................................... 0.8855 0.9201
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC................ 0.9740 0.9821
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
[[Page 27526]]
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8493 0.8942
Pennington, SD
6680 Reading, PA................................... 0.9467 0.9728
Berks, PA
6690 Redding, CA................................... 1.1631 1.1090
Shasta, CA
6720 Reno, NV...................................... 1.1043 1.0703
Washoe, NV
6740 Richland-Kennewick-Pasco, WA.................. 0.9993 0.9995
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 0.9189 0.9437
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780 *Riverside-San Bernardino, CA................. 1.1251 1.1166
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA................................... 0.8721 0.9105
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.0452 1.0307
Olmsted, MN
6840 *Rochester, NY................................ 0.9611 1.0024
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.9015 0.9315
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.8951 0.9269
Edgecombe, NC
Nash, NC
6920 *Sacramento, CA............................... 1.2382 1.1923
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9605 0.9728
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9478 0.9640
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.8570 0.8997
Andrews, MO
Buchanan, MO
7040 *St. Louis, MO-IL............................. 0.8926 0.9529
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080 Salem, OR..................................... 0.9749 0.9901
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.3835 1.2489
Monterey, CA
7160 *Salt Lake City-Ogden, UT..................... 0.9677 1.0071
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.7594 0.8282
Tom Green, TX
7240 *San Antonio, TX.............................. 0.8365 0.9115
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 *San Diego, CA................................ 1.2183 1.1791
San Diego, CA
7360 *San Francisco, CA............................ 1.4210 1.3102
Marin, CA
San Francisco, CA
San Mateo, CA
7400 *San Jose, CA................................. 1.4435 1.3244
Santa Clara, CA
7440 *San Juan-Bayamon, PR......................... 0.4616 0.6066
Aguas Buenas, PR
Barceloneta, PR
Bayamon, PR
Canovanas, PR
Carolina, PR
Catano, PR
Ceiba, PR
Comerio, PR
Corozal, PR
Dorado, PR
Fajardo, PR
Florida, PR
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, PR
Luguillo, PR
Manati, PR
Morovis, PR
Naguabo, PR
Naranjito, PR
Rio Grande, PR
San Juan, PR
Toa Alta, PR
Toa Baja, PR
Trujillo Alto, PR
Vega Alta, PR
Vega Baja, PR
Yabucoa, PR
7460 San Luis Obispo-Atascadero-Paso Robles, CA.... 1.1587 1.1061
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.1267 1.0851
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.3551 1.2313
Santa Cruz, CA
7490 Santa Fe, NM.................................. 1.0847 1.0573
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA................................ 1.2558 1.1688
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 0.9770 0.9842
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 1.0089 1.0061
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton-Wilkes-Barre-Hazleton, PA............ 0.8767 0.9138
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 *Seattle-Bellevue-Everett, WA................. 1.1410 1.1274
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA.................................... 0.8764 0.9136
Mercer, PA
7620 Sheboygan, WI................................. 0.7782 0.8422
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.8650 0.9055
Grayson, TX
7680 Shreveport-Bossier City, LA................... 0.9379 0.9570
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8331 0.8825
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD............................... 0.8606 0.9023
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................ 0.9957 0.9971
St. Joseph, IN
[[Page 27527]]
7840 Spokane, WA................................... 1.0548 1.0372
Spokane, WA
7880 Springfield, IL............................... 0.8783 0.9150
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.7840 0.8465
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA............................... 1.0609 1.0552
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.8875 0.9215
Centre, PA
8080 Steubenville-Weirton, OH-WV................... 0.8244 0.9024
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.1417 1.0997
San Joaquin, CA
8140 Sumter, SC.................................... 0.7716 0.8373
Sumter, SC
8160 Syracuse, NY.................................. 0.9406 0.9589
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.................................... 1.0891 1.0655
Pierce, WA
8240 Tallahassee, FL............................... 0.8332 0.8825
Gadsden, FL
Leon, FL
8280 *Tampa-St. Petersburg-Clearwater, FL.......... 0.9322 0.9817
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN............................... 0.8611 0.9027
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX................... 0.8484 0.8935
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 1.0383 1.0445
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 1.0108 1.0074
Shawnee, KS
8480 Trenton, NJ................................... 1.0572 1.0388
Mercer, NJ
8520 Tucson, AZ.................................... 0.9050 0.9339
Pima, AZ
8560 Tulsa, OK..................................... 0.8113 0.8666
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................ 0.7723 0.8378
Tuscaloosa, AL
8640 Tyler, TX..................................... 1.0158 1.0108
Smith, TX
8680 Utica-Rome, NY................................ 0.8421 0.8890
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.3483 1.2271
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.1169 1.0786
Ventura, CA
8750 Victoria, TX.................................. 0.8478 0.8931
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 1.0015 1.0010
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA................ 1.0174 1.0119
Tulare, CA
8800 Waco, TX...................................... 0.7789 0.8427
McLennan, TX
8840 *Washington, DC-MD-VA-WV...................... 1.0842 1.0886
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpepper, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City, VA
King George, VA
Loudoun, VA
Manassas City, VA
Manassas Park City, VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Berkeley, WV
Jefferson, WV
8920 Waterloo-Cedar Falls, IA...................... 0.8724 0.9108
Black Hawk, IA
8940 Wausau, WI.................................... 1.0347 1.0236
Marathon, WI
8960 West Palm Beach-Boca Raton, FL................ 1.0016 1.0036
Palm Beach, FL
9000 Wheeling, OH-WV............................... 0.7580 0.8313
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.9447 0.9618
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.8070 0.8634
Archer, TX
Wichita, TX
9140 Williamsport, PA.............................. 0.8487 0.8937
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.1341 1.1063
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9072 0.9355
New Hanover, NC
Brunswick, NC
9260 Yakima, WA.................................... 1.0049 1.0034
Yakima, WA
9270 Yolo, CA...................................... 1.1470 1.0985
Yolo, CA
9280 York, PA...................................... 0.9124 0.9391
York, PA
9320 Youngstown-Warren, OH......................... 0.9764 0.9838
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0437 1.0297
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 0.9518 0.9667
Yuma, AZ
------------------------------------------------------------------------
* Large Urban Area
Table 4b.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7160 0.7955
Alaska.............................................. 1.2472 1.2550
Arizona............................................. 0.7946 0.8543
Arkansas............................................ 0.7000 0.7833
California.......................................... 0.9991 1.0010
Colorado............................................ 0.8156 0.8697
Connecticut......................................... 1.2788 1.2189
Delaware............................................ 0.9464 0.9630
Florida............................................. 0.8677 0.9084
Georgia............................................. 0.7659 0.8331
Hawaii.............................................. 1.0268 1.0771
Idaho............................................... 0.8356 0.8843
Illinois............................................ 0.7567 0.8286
Indiana............................................. 0.8119 0.8718
Iowa................................................ 0.7394 0.8132
Kansas.............................................. 0.7113 0.7922
Kentucky............................................ 0.7772 0.8419
Louisiana........................................... 0.7284 0.8055
Maine............................................... 0.8335 0.8827
Maryland............................................ 0.8446 0.8908
Massachusetts....................................... 1.0794 1.0537
Michigan............................................ 0.8837 0.9188
Minnesota........................................... 0.8161 0.8704
Mississippi......................................... 0.6808 0.7685
Missouri............................................ 0.7249 0.8044
[[Page 27528]]
Montana............................................. 0.8137 0.8683
Nebraska............................................ 0.7245 0.8020
Nevada.............................................. 0.8795 0.9158
New Hampshire....................................... 0.9776 0.9895
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.7873 0.8489
New York............................................ 0.8565 0.8994
North Carolina...................................... 0.7945 0.8565
North Dakota........................................ 0.7370 0.8114
Ohio................................................ 0.8349 0.8909
Oklahoma............................................ 0.6963 0.7805
Oregon.............................................. 0.9715 0.9813
Pennsylvania........................................ 0.8480 0.8939
Puerto Rico......................................... 0.4182 0.5505
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.7679 0.8356
South Dakota........................................ 0.7085 0.7898
Tennessee........................................... 0.7372 0.8116
Texas............................................... 0.7430 0.8166
Utah................................................ 0.8854 0.9200
Vermont............................................. 0.8941 0.9287
Virginia............................................ 0.7760 0.8422
Washington.......................................... 0.9956 0.9978
West Virginia....................................... 0.7943 0.8541
Wisconsin........................................... 0.8449 0.8914
Wyoming............................................. 0.8202 0.8731
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 4c.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That are Reclassified
------------------------------------------------------------------------
Wage
Area reclassified to index GAF
------------------------------------------------------------------------
Abilene, TX......................................... 0.8055 0.8623
Albuquerque, NM..................................... 0.9390 0.9578
Alexandria, LA...................................... 0.8213 0.8739
Amarillo, TX........................................ 0.8557 0.8988
Anchorage, AK....................................... 1.3285 1.2147
Asheville, NC....................................... 0.9365 0.9561
Atlanta, GA......................................... 0.9986 0.9990
Bangor, ME.......................................... 0.9412 0.9594
Baton Rouge, LA..................................... 0.8442 0.8905
Benton Harbor, MI................................... 0.8553 0.8985
Benton Harbor, MI (Rural Michigan Hosp.)............ 0.8837 0.9188
Billings, MT........................................ 0.8903 0.9235
Birmingham, AL...................................... 0.9047 0.9337
Bismarck, ND........................................ 0.7976 0.8565
Boise City, ID...................................... 0.9269 0.9493
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1639 1.1095
Caguas, PR.......................................... 0.4661 0.5929
Champaign-Urbana, IL................................ 0.8999 0.9303
Charleston-North Charleston, SC..................... 0.8984 0.9293
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9631 0.9746
Charlottesville, VA................................. 0.9006 0.9308
Chattanooga, TN-GA.................................. 0.8867 0.9210
Chicago, IL......................................... 1.0653 1.0443
Cincinnati, OH-KY-IN................................ 0.9477 0.9639
Cleveland-Lorain-Elyria, OH......................... 0.9908 0.9937
Columbia, MO........................................ 0.8919 0.9246
Columbus, OH........................................ 0.9699 0.9793
Dallas, TX.......................................... 0.9530 0.9676
Davenport-Moline-Rock Island, IA-IL................. 0.8407 0.8880
Denver, CO.......................................... 1.0291 1.0198
Des Moines, IA...................................... 0.8772 0.9142
Duluth-Superior, MN-WI.............................. 0.9437 0.9611
Dutchess County, NY................................. 1.0309 1.0211
Elkhart-Goshen, IN.................................. 0.8820 0.9176
Eugene-Springfield, OR.............................. 1.1503 1.1006
Fargo-Moorhead, ND-MN............................... 0.8860 0.9205
Fayetteville, NC.................................... 0.8658 0.9060
Flagstaff, AR-UT.................................... 0.8848 0.9196
Flint, MI........................................... 1.1273 1.0855
Florence, AL........................................ 0.8157 0.8698
Florence, SC........................................ 0.8614 0.9029
Fort Lauderdale, FL................................. 1.0968 1.0653
Fort Pierce-Port St. Lucie, FL...................... 1.0049 1.0034
Fort Smith, AR-OK................................... 0.7885 0.8498
Fort Walton Beach, FL............................... 0.8978 0.9288
Fort Worth-Arlington, TX............................ 1.0095 1.0065
Gadsden, AL......................................... 0.8901 0.9234
Gary, IN............................................ 0.9176 0.9428
Grand Forks, ND-MN.................................. 0.9228 0.9465
Grand Junction, CO.................................. 0.8847 0.9195
Grand Rapids-Muskegon-Holland, MI................... 1.0088 1.0060
Great Falls, MT..................................... 0.9007 0.9309
Greeley, CO......................................... 0.9409 0.9591
Green Bay, WI....................................... 0.9387 0.9576
Greensboro-Winston-Salem-High Point, NC............. 0.9327 0.9534
Greenville-Spartanburg-Anderson, SC................. 0.8947 0.9266
Hartford, CT........................................ 1.2218 1.1470
Honolulu, HI........................................ 1.1487 1.0996
Houston, TX......................................... 0.9790 0.9856
Huntington-Ashland, WV-KY-OH........................ 0.9194 0.9441
Huntsville, AL...................................... 0.8040 0.8612
Indianapolis, IN.................................... 0.9833 0.9885
Jackson, MS......................................... 0.7906 0.8514
Jacksonville, FL.................................... 0.9018 0.9317
Johnson City-Kingsport-Bristol, TN-VA............... 0.8921 0.9248
Joplin, MO.......................................... 0.7409 0.8144
Kalamazoo-Battlecreek, MI........................... 1.0462 1.0314
Kansas City, KS-MO.................................. 0.9522 0.9670
Knoxville, TN....................................... 0.8520 0.8961
Lafayette, LA....................................... 0.8183 0.8717
Lansing-East Lansing, MI............................ 1.0016 1.0011
Las Vegas, NV-AZ.................................... 1.0894 1.0604
Lexington, KY....................................... 0.8387 0.8865
Lima, OH............................................ 0.8752 0.9128
Lincoln, NE......................................... 0.9059 0.9346
Little Rock-North Little Rock, AR................... 0.8616 0.9030
Longview-Marshall, TX............................... 0.8495 0.8943
Los Angeles-Long Beach, CA.......................... 1.2396 1.1585
Louisville, KY-IN................................... 0.9445 0.9617
Macon, GA........................................... 0.8460 0.8918
Madison, WI......................................... 1.0048 1.0033
Mansfield, OH....................................... 0.8543 0.8978
Medford-Ashland, OR................................. 1.0213 1.0145
Memphis, TN-AR-MS................................... 0.8185 0.8718
Middlesex-Somerset-Hunterdon, NJ.................... 1.0777 1.0526
Milwaukee-Waukesha, WI.............................. 0.9667 0.9771
Minneapolis-St. Paul, MN-WI......................... 1.0785 1.0531
Modesto, CA......................................... 1.0135 1.0092
Monmouth-Ocean, NJ.................................. 1.0572 1.0388
Montgomery, AL...................................... 0.7949 0.8545
Nashville, TN....................................... 0.9065 0.9350
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2778 1.1828
New London-Norwich, CT.............................. 1.2345 1.1552
New Orleans, LA..................................... 0.9434 0.9609
New York, NY........................................ 1.4041 1.2616
Newark, NJ.......................................... 1.0956 1.0645
Oakland, CA......................................... 1.5113 1.3268
Odessa-Midland, TX.................................. 0.8552 0.8984
Oklahoma City, OK................................... 0.8463 0.8920
Omaha, NE-IA........................................ 0.9425 0.9603
Orange County, CA................................... 1.1929 1.1284
Peoria-Pekin, IL.................................... 0.8923 0.9249
Philadelphia, PA-NJ................................. 1.1197 1.0805
Pittsburgh, PA...................................... 0.9564 0.9699
Portland, ME........................................ 0.9615 0.9735
Portland-Vancouver, OR-WA........................... 1.1267 1.0851
Provo-Orem, UT...................................... 1.0139 1.0095
Raleigh-Durham-Chapel Hill, NC...................... 0.9615 0.9735
Rapid City, SD...................................... 0.8493 0.8942
Roanoke, VA......................................... 0.8721 0.9105
Rochester, MN....................................... 1.0452 1.0307
Rockford, IL........................................ 0.9015 0.9315
Sacramento, CA...................................... 1.2382 1.1576
Saginaw-Bay City-Midland, MI........................ 0.9605 0.9728
St. Cloud, MN....................................... 0.9478 0.9640
St. Louis, MO-IL.................................... 0.8926 0.9251
Salt Lake City-Ogden, UT............................ 0.9677 0.9778
San Diego, CA....................................... 1.2183 1.1448
San Francisco, CA................................... 1.4210 1.2720
San Jose, CA........................................ 1.4435 1.2858
Santa Rosa, CA...................................... 1.2430 1.1606
Sarasota-Bradenton, FL.............................. 0.9770 0.9842
Seattle-Bellevue-Everett, WA........................ 1.1410 1.0945
Sharon, PA.......................................... 0.8764 0.9136
Sherman-Denison, TX................................. 0.8650 0.9055
Sioux Falls, SD..................................... 0.8606 0.9023
South Bend, IN...................................... 0.9957 0.9971
Springfield, IL..................................... 0.8783 0.9150
Springfield, MO..................................... 0.7840 0.8465
Stockton-Lodi, CA................................... 1.1417 1.0950
Syracuse, NY........................................ 0.9406 0.9589
Tacoma, WA.......................................... 1.0891 1.0602
Tampa-St. Petersburg-Clearwater, FL................. 0.9322 0.9531
[[Page 27529]]
Texarkana, AR-Texarkana, TX......................... 0.8484 0.8935
Toledo, OH.......................................... 1.0383 1.0261
Topeka, KS.......................................... 0.9817 0.9874
Tucson, AZ.......................................... 0.9050 0.9339
Tulsa, OK........................................... 0.8113 0.8666
Tyler, TX........................................... 0.9717 0.9805
Victoria, TX........................................ 0.8259 0.8772
Washington, DC-MD-VA-WV............................. 1.0842 1.0569
Waterloo-Cedar Falls, IA............................ 0.8601 0.9019
Wausau, WI.......................................... 0.9720 0.9807
Wichita, KS......................................... 0.9282 0.9503
Rural Alabama....................................... 0.7160 0.7955
Rural Florida....................................... 0.8677 0.9074
Rural Kentucky...................................... 0.7772 0.8415
Rural Louisiana..................................... 0.7284 0.8049
Rural Michigan...................................... 0.8837 0.9188
Rural Minnesota..................................... 0.8161 0.8701
Rural New Hampshire................................. 0.9776 0.9846
Rural North Carolina................................ 0.7945 0.8542
Rural Virginia...................................... 0.7760 0.8406
Rural Washington.................................... 0.9956 0.9970
Rural West Virginia................................. 0.7943 0.8541
Rural Wyoming....................................... 0.8202 0.8731
------------------------------------------------------------------------
Table 4d.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 15.4795
Aguadilla, PR................................................ 8.6418
Akron, OH.................................................... 19.2662
Albany, GA................................................... 16.2968
Albany-Schenectady-Troy, NY.................................. 16.6016
Albuquerque, NM.............................................. 18.3100
Alexandria, LA............................................... 15.8746
Allentown-Bethlehem-Easton, PA............................... 19.5376
Altoona, PA.................................................. 18.5951
Amarillo, TX................................................. 16.6936
Anchorage, AK................................................ 25.8567
Ann Arbor, MI................................................ 22.8035
Anniston, AL................................................. 15.3104
Appleton-Oshkosh-Neenah, WI.................................. 17.3835
Arecibo, PR.................................................. 9.0343
Asheville, NC................................................ 18.2517
Athens, GA................................................... 18.0640
Atlanta, GA.................................................. 19.6832
Atlantic-Cape May, NJ........................................ 21.6594
Augusta-Aiken, GA-SC......................................... 17.2642
Austin-San Marcos, TX........................................ 18.0500
Bakersfield, CA.............................................. 19.9031
Baltimore, MD................................................ 19.1581
Bangor, ME................................................... 18.3630
Barnstable-Yarmouth, MA...................................... 26.6928
Baton Rouge, LA.............................................. 16.4700
Beaumont-Port Arthur, TX..................................... 16.7355
Bellingham, WA............................................... 22.1285
Benton Harbor, MI............................................ 16.5971
Bergen-Passaic, NJ........................................... 22.8591
Billings, MT................................................. 17.3702
Biloxi-Gulfport-Pascagoula, MS............................... 16.7252
Binghamton, NY............................................... 17.2505
Birmingham, AL............................................... 17.6503
Bismarck, ND................................................. 15.0933
Bloomington, IN.............................................. 16.8155
Bloomington-Normal, IL....................................... 17.4035
Boise City, ID............................................... 18.0695
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 22.7069
Boulder-Longmont, CO......................................... 18.3061
Brazoria, TX................................................. 17.9908
Bremerton, WA................................................ 21.3152
Brownsville-Harlingen-San Benito, TX......................... 16.7030
Bryan-College Station, TX.................................... 17.0898
Buffalo-Niagara Falls, NY.................................... 17.7977
Burlington, VT............................................... 17.8037
Caguas, PR................................................... 9.0488
Canton-Massillon, OH......................................... 16.9098
Casper, WY................................................... 17.2484
Cedar Rapids, IA............................................. 16.5386
Champaign-Urbana, IL......................................... 18.3634
Charleston-North Charleston, SC.............................. 17.5265
Charleston, WV............................................... 18.6261
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 18.7900
Charlottesville, VA.......................................... 17.9005
Chattanooga, TN-GA........................................... 17.2991
Cheyenne, WY................................................. 15.0126
Chicago, IL.................................................. 20.9843
Chico-Paradise, CA........................................... 20.3689
Cincinnati, OH-KY-IN......................................... 18.4886
Clarksville-Hopkinsville, TN-KY.............................. 15.0873
Cleveland-Lorain-Elyria, OH.................................. 19.3306
Colorado Springs, CO......................................... 18.4479
Columbia, MO................................................. 17.4002
Columbia, SC................................................. 17.9066
Columbus, GA-AL.............................................. 14.9336
Columbus, OH................................................. 18.9232
Corpus Christi, TX........................................... 16.8587
Cumberland, MD-WV............................................ 16.8031
Dallas, TX................................................... 18.5928
Danville, VA................................................. 16.6152
Davenport-Moline-Rock Island, IA-IL.......................... 16.4021
Dayton-Springfield, OH....................................... 18.6930
Daytona Beach, FL............................................ 17.3459
Decatur, AL.................................................. 16.3934
Decatur, IL.................................................. 15.3452
Denver, CO................................................... 20.0780
Des Moines, IA............................................... 17.1139
Detroit, MI.................................................. 20.9694
Dothan, AL................................................... 15.1351
Dover, DE.................................................... 17.5916
Dubuque, IA.................................................. 15.8987
Duluth-Superior, MN-WI....................................... 18.4105
Dutchess County, NY.......................................... 20.6881
Eau Claire, WI............................................... 16.9692
El Paso, TX.................................................. 18.5059
Elkhart-Goshen, IN........................................... 17.2083
Elmira, NY................................................... 16.4576
Enid, OK..................................................... 15.3724
Erie, PA..................................................... 17.8263
Eugene-Springfield, OR....................................... 22.0384
Evansville, Henderson, IN-KY................................. 17.5397
Fargo-Moorhead, ND-MN........................................ 17.5775
Fayetteville, NC............................................. 17.6077
Fayetteville-Springdale-Rogers, AR........................... 14.1177
Flagstaff, AZ-UT............................................. 17.6344
Flint, MI.................................................... 21.9933
Florence, AL................................................. 15.5886
Florence, SC................................................. 16.8047
Fort Collins-Loveland, CO.................................... 20.7345
Fort Lauderdale, FL.......................................... 20.5796
Fort Myers-Cape Coral, FL.................................... 17.7400
Fort Pierce-Port St. Lucie, FL............................... 19.8836
Fort Smith, AR-OK............................................ 15.3772
Fort Walton Beach, FL........................................ 17.9217
Fort Wayne, IN............................................... 17.2046
Fort Worth-Arlington, TX..................................... 19.6953
Fresno, CA................................................... 21.8549
Gadsden, AL.................................................. 17.3656
Gainesville, FL.............................................. 18.4465
Galveston-Texas City, TX..................................... 21.5032
Gary, IN..................................................... 18.8135
Glens Falls, NY.............................................. 16.6999
Goldsboro, NC................................................ 16.4109
Grand Forks, ND-MN........................................... 17.6200
Grand Junction, CO........................................... 16.2899
Grand Rapids-Muskegon-Holland, MI............................ 19.6810
Great Falls, MT.............................................. 16.9748
Greeley, CO.................................................. 18.9481
Green Bay, WI................................................ 17.6730
Greensboro-Winston-Salem-High Point, NC...................... 18.1974
Greenville, NC............................................... 17.7503
Greenville-Spartanburg-Anderson, SC.......................... 17.4547
Hagerstown, MD............................................... 17.9394
Hamilton-Middletown, OH...................................... 18.5631
Harrisburg-Lebanon-Carlisle, PA.............................. 19.8630
Hartford, CT................................................. 24.1823
Hattiesburg, MS.............................................. 14.1809
Hickory-Morganton-Lenoir, NC................................. 16.8672
Honolulu, HI................................................. 22.4099
Houma, LA.................................................... 15.3009
Houston, TX.................................................. 19.1004
Huntington-Ashland, WV-KY-OH................................. 17.9378
Huntsville, AL............................................... 15.8903
Indianapolis, IN............................................. 19.4109
Iowa City, IA................................................ 18.3037
Jackson, MI.................................................. 17.6864
Jackson, MS.................................................. 15.3259
Jackson, TN.................................................. 16.2704
Jacksonville, FL............................................. 17.5917
Jacksonville, NC............................................. 13.7955
Jamestown, NY................................................ 14.9815
Janesville-Beloit, WI........................................ 16.9030
Jersey City, NJ.............................................. 22.2562
Johnson City-Kingsport-Bristol, TN-VA........................ 17.3717
Johnstown, PA................................................ 16.4213
Joplin, MO................................................... 14.3989
Kalamazoo-Battlecreek, MI.................................... 20.6127
Kankakee, IL................................................. 17.5542
Kansas City, KS-MO........................................... 18.5772
Kenosha, WI.................................................. 17.8819
Killeen-Temple, TX........................................... 20.3189
Knoxville, TN................................................ 16.6222
Kokomo, IN................................................... 16.7962
La Crosse, WI-MN............................................. 16.8513
Lafayette, LA................................................ 15.9607
Lafayette, IN................................................ 17.1635
Lake Charles, LA............................................. 15.7084
Lakeland-Winter Haven, FL.................................... 17.1559
Lancaster, PA................................................ 18.7384
Lansing-East Lansing, MI..................................... 19.5408
Laredo, TX................................................... 13.8360
Las Cruces, NM............................................... 16.6145
[[Page 27530]]
Las Vegas, NV-AZ............................................. 21.2545
Lawrence, KS................................................. 16.8098
Lawton, OK................................................... 16.2681
Lewiston-Auburn, ME.......................................... 18.3998
Lexington, KY................................................ 16.3501
Lima, OH..................................................... 17.0746
Lincoln, NE.................................................. 17.9352
Little Rock-North Little Rock, AR............................ 16.8095
Longview-Marshall, TX........................................ 16.8433
Los Angeles-Long Beach, CA................................... 24.1067
Louisville, KY-IN............................................ 18.4271
Lubbock, TX.................................................. 16.6316
Lynchburg, VA................................................ 15.6776
Macon, GA.................................................... 17.2388
Madison, WI.................................................. 19.6027
Mansfield, OH................................................ 16.6677
Mayaguez, PR................................................. 8.1673
McAllen-Edinburg-Mission, TX................................. 16.5870
Medford-Ashland, OR.......................................... 19.6857
Melbourne-Titusville-Palm Bay, FL............................ 17.7314
Memphis, TN-AR-MS............................................ 15.9681
Merced, CA................................................... 20.8439
Miami, FL.................................................... 19.3734
Middlesex-Somerset-Hunterdon, NJ............................. 21.0732
Milwaukee-Waukesha, WI....................................... 18.8591
Minneapolis-St. Paul, MN-WI.................................. 21.0411
Mobile, AL................................................... 15.6052
Modesto, CA.................................................. 20.7262
Monmouth-Ocean, NJ........................................... 21.1523
Monroe, LA................................................... 16.0633
Montgomery, AL............................................... 15.5087
Muncie, IN................................................... 18.9936
Myrtle Beach, SC............................................. 15.2138
Naples, FL................................................... 19.9423
Nashville, TN................................................ 17.6844
Nassau-Suffolk, NY........................................... 26.4295
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 24.8405
New London-Norwich, CT....................................... 23.9754
New Orleans, LA.............................................. 18.4047
New York, NY................................................. 27.3928
Newark, NJ................................................... 22.9650
Newburgh, NY-PA.............................................. 21.1274
Norfolk-Virginia Beach-Newport News, VA-NC................... 16.2433
Oakland, CA.................................................. 29.3295
Ocala, FL.................................................... 17.5573
Odessa-Midland, TX........................................... 16.5854
Oklahoma City, OK............................................ 16.5112
Olympia, WA.................................................. 20.9003
Omaha, NE-IA................................................. 18.3867
Orange County, CA............................................ 23.3969
Orlando, FL.................................................. 18.5157
Owensboro, KY................................................ 14.7838
Panama City, FL.............................................. 15.7629
Parkersburg-Marietta, WV-OH.................................. 15.4018
Pensacola, FL................................................ 16.0203
Peoria-Pekin, IL............................................. 17.4092
Philadelphia, PA-NJ.......................................... 21.8450
Phoenix-Mesa, AZ............................................. 19.1821
Pine Bluff, AR............................................... 15.4205
Pittsburgh, PA............................................... 18.9757
Pittsfield, MA............................................... 20.6216
Ponce, PR.................................................... 8.7784
Portland, ME................................................. 18.7580
Portland-Vancouver, OR-WA.................................... 21.9821
Providence-Warwick, RI....................................... 21.6876
Provo-Orem, UT............................................... 19.7809
Pueblo, CO................................................... 16.1970
Punta Gorda, FL.............................................. 16.1612
Racine, WI................................................... 17.2751
Raleigh-Durham-Chapel Hill, NC............................... 19.0031
Rapid City, SD............................................... 16.5325
Reading, PA.................................................. 18.4690
Redding, CA.................................................. 22.6922
Reno, NV..................................................... 21.5443
Richland-Kennewick-Pasco, WA................................. 19.4956
Richmond-Petersburg, VA...................................... 17.9271
Riverside-San Bernardino, CA................................. 22.2324
Roanoke, VA.................................................. 17.0151
Rochester, MN................................................ 20.3908
Rochester, NY................................................ 18.7505
Rockford, IL................................................. 17.5872
Rocky Mount, NC.............................................. 17.4626
Sacramento, CA............................................... 24.1558
Saginaw-Bay City-Midland, MI................................. 18.5818
St. Cloud, MN................................................ 18.4907
St. Joseph, MO............................................... 16.7196
St. Louis, MO-IL............................................. 17.4144
Salem, OR.................................................... 19.0205
Salinas, CA.................................................. 26.9904
Salt Lake City-Ogden, UT..................................... 18.8799
San Angelo, TX............................................... 14.8158
San Antonio, TX.............................................. 16.3206
San Diego, CA................................................ 23.7299
San Francisco, CA............................................ 27.8220
San Jose, CA................................................. 28.2911
San Juan-Bayamon, PR......................................... 9.0059
San Luis Obispo-Atascadero-Paso Robles, CA................... 22.6053
Santa Barbara-Santa Maria-Lompoc, CA......................... 21.9816
Santa Cruz-Watsonville, CA................................... 26.4364
Santa Fe, NM................................................. 21.1622
Santa Rosa, CA............................................... 24.4999
Sarasota-Bradenton, FL....................................... 19.0607
Savannah, GA................................................. 19.6834
Scranton-Wilkes Barre-Hazleton, PA........................... 17.1047
Seattle-Bellevue-Everett, WA................................. 22.2595
Sharon, PA................................................... 17.0979
Sheboygan, WI................................................ 15.1817
Sherman-Denison, TX.......................................... 16.8423
Shreveport-Bossier City, LA.................................. 18.2987
Sioux City, IA-NE............................................ 16.2539
Sioux Falls, SD.............................................. 16.7892
South Bend, IN............................................... 19.4248
Spokane, WA.................................................. 20.5788
Springfield, IL.............................................. 17.1355
Springfield, MO.............................................. 15.2957
Springfield, MA.............................................. 20.6983
State College, PA............................................ 17.3139
Steubenville-Weirton, OH-WV.................................. 16.0839
Stockton-Lodi, CA............................................ 22.1532
Sumter, SC................................................... 15.0540
Syracuse, NY................................................. 18.3462
Tacoma, WA................................................... 21.2353
Tallahassee, FL.............................................. 16.2555
Tampa-St. Petersburg-Clearwater, FL.......................... 18.0837
Terre Haute, IN.............................................. 16.7989
Texarkana, AR-Texarkana, TX.................................. 16.5261
Toledo, OH................................................... 20.2562
Topeka, KS................................................... 19.7210
Trenton, NJ.................................................. 20.6250
Tucson, AZ................................................... 17.6383
Tulsa, OK.................................................... 15.8281
Tuscaloosa, AL............................................... 15.0679
Tyler, TX.................................................... 19.8177
Utica-Rome, NY............................................... 16.4296
Vallejo-Fairfield-Napa, CA................................... 27.2883
Ventura, CA.................................................. 22.5369
Victoria, TX................................................. 16.5405
Vineland-Millville-Bridgeton, NJ............................. 19.5394
Visalia-Tulare-Porterville, CA............................... 19.8483
Waco, TX..................................................... 15.1959
Washington, DC-MD-VA-WV...................................... 21.1518
Waterloo-Cedar Falls, IA..................................... 17.0208
Wausau, WI................................................... 20.1856
West Palm Beach-Boca Raton, FL............................... 19.9482
Wheeling, OH-WV.............................................. 14.7877
Wichita, KS.................................................. 18.4305
Wichita Falls, TX............................................ 15.7442
Williamsport, PA............................................. 16.5567
Wilmington-Newark, DE-MD..................................... 22.1249
Wilmington, NC............................................... 17.6987
Yakima, WA................................................... 19.6049
Yolo, CA..................................................... 22.3769
York, PA..................................................... 17.8006
Youngstown-Warren, OH........................................ 19.0484
Yuba City, CA................................................ 20.3622
Yuma, AZ..................................................... 18.5693
------------------------------------------------------------------------
Table 4e.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
Average
Nonurban area hourly
wage
------------------------------------------------------------------------
Alabama...................................................... 13.9126
Alaska....................................................... 24.3314
Arizona...................................................... 15.5017
Arkansas..................................................... 13.6566
California................................................... 19.4927
Colorado..................................................... 15.9126
Connecticut.................................................. 24.9480
Delaware..................................................... 18.4636
Florida...................................................... 16.9290
Georgia...................................................... 14.9414
Hawaii....................................................... 20.0330
Idaho........................................................ 16.3016
Illinois..................................................... 14.7630
Indiana...................................................... 15.8402
Iowa......................................................... 14.4246
Kansas....................................................... 13.8771
Kentucky..................................................... 15.1633
Louisiana.................................................... 14.1714
Maine........................................................ 16.2618
Maryland..................................................... 16.4778
Massachusetts................................................ 21.0582
Michigan..................................................... 17.2254
Minnesota.................................................... 15.9225
Mississippi.................................................. 13.2817
Missouri..................................................... 14.1433
Montana...................................................... 15.8750
Nebraska..................................................... 14.1342
Nevada....................................................... 17.1588
New Hampshire................................................ 19.0608
New Jersey \1\............................................... .........
New Mexico................................................... 15.3596
New York..................................................... 16.7103
North Carolina............................................... 15.4962
North Dakota................................................. 14.3775
Ohio......................................................... 16.2883
[[Page 27531]]
Oklahoma..................................................... 13.5853
Oregon....................................................... 18.9527
Pennsylvania................................................. 16.5230
Puerto Rico.................................................. 8.1591
Rhode Island \1\............................................. .........
South Carolina............................................... 14.9812
South Dakota................................................. 13.8219
Tennessee.................................................... 14.3822
Texas........................................................ 14.4957
Utah......................................................... 17.2737
Vermont...................................................... 17.4440
Virginia..................................................... 15.1073
Washington................................................... 19.4229
West Virginia................................................ 15.4577
Wisconsin.................................................... 16.4842
Wyoming...................................................... 16.0015
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric Mean Length of Stay,
and Length of Stay Outlier Cutoff Points Used in the Prospective Payment System
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic Outlier
weights mean LOS mean LOS threshold
----------------------------------------------------------------------------------------------------------------
1........... 01 SURG CRANIOTOMY AGE >17 3.0445 7.7 11.1 32
EXCEPT FOR TRAUMA.
2........... 01 SURG CRANIOTOMY FOR TRAUMA 3.0241 8.4 11.5 32
AGE >17.
3........... 01 SURG *CRANIOTOMY AGE 0-17... 1.9159 12.7 12.7 37
4........... 01 SURG SPINAL PROCEDURES..... 2.3330 5.9 9.1 30
5........... 01 SURG EXTRACRANIAL VASCULAR 1.5149 3.3 4.4 26
PROCEDURES.
6........... 01 SURG CARPAL TUNNEL RELEASE. .7359 2.4 3.4 25
7........... 01 SURG PERIPH & CRANIAL NERVE 2.4935 8.2 12.6 32
& OTHER NERV SYST PROC
W CC.
8........... 01 SURG PERIPH & CRANIAL NERVE 1.1419 2.8 4.1 27
& OTHER NERV SYST PROC
W/O CC.
9........... 01 MED SPINAL DISORDERS & 1.2522 5.4 7.7 29
INJURIES.
10.......... 01 MED NERVOUS SYSTEM 1.2209 5.7 8.1 30
NEOPLASMS W CC.
11.......... 01 MED NERVOUS SYSTEM .8020 3.5 5.0 28
NEOPLASMS W/O CC.
12.......... 01 MED DEGENERATIVE NERVOUS .9435 5.4 7.6 29
SYSTEM DISORDERS.
13.......... 01 MED MULTIPLE SCLEROSIS & .7799 5.0 6.3 29
CEREBELLAR ATAXIA.
14.......... 01 MED SPECIFIC 1.2003 5.5 7.5 30
CEREBROVASCULAR
DISORDERS EXCEPT TIA.
15.......... 01 MED TRANSIENT ISCHEMIC .7232 3.5 4.4 27
ATTACK & PRECEREBRAL
OCCLUSIONS.
16.......... 01 MED NONSPECIFIC 1.0390 4.9 6.6 29
CEREBROVASCULAR
DISORDERS W CC.
17.......... 01 MED NONSPECIFIC .6308 3.0 4.0 26
CEREBROVASCULAR
DISORDERS W/O CC.
18.......... 01 MED CRANIAL & PERIPHERAL .9345 4.8 6.4 29
NERVE DISORDERS W CC.
19.......... 01 MED CRANIAL & PERIPHERAL .6258 3.4 4.5 27
NERVE DISORDERS W/O CC.
20.......... 01 MED NERVOUS SYSTEM 2.4782 8.5 11.5 33
INFECTION EXCEPT VIRAL
MENINGITIS.
21.......... 01 MED VIRAL MENINGITIS...... 1.4972 5.8 7.9 30
22.......... 01 MED HYPERTENSIVE .8356 3.8 4.9 28
ENCEPHALOPATHY.
23.......... 01 MED NONTRAUMATIC STUPOR & .8053 3.6 5.1 28
COMA.
24.......... 01 MED SEIZURE & HEADACHE AGE .9707 4.2 5.8 28
>17 W CC.
25.......... 01 MED SEIZURE & HEADACHE AGE .5791 3.0 3.9 24
>17 W/O CC.
26.......... 01 MED SEIZURE & HEADACHE AGE .7381 3.3 4.6 27
0-17.
27.......... 01 MED TRAUMATIC STUPOR & 1.3186 3.7 6.3 28
COMA, COMA >1 HR.
28.......... 01 MED TRAUMATIC STUPOR & 1.2075 4.8 7.2 29
COMA, COMA <1 hr="" age="">17 W CC.
29.......... 01 MED TRAUMATIC STUPOR & .6382 3.0 4.1 27
COMA, COMA <1 hr="" age="">17 W/O CC.
30.......... 01 MED *TRAUMATIC STUPOR & .3240 2.0 2.0 17
COMA, COMA <1 hr="" age="" 0-="" 17.="" 31..........="" 01="" med="" concussion="" age="">17 W .8367 3.7 5.4 28
CC.
32.......... 01 MED CONCUSSION AGE >17 W/O .4887 2.3 3.2 21
CC.
33.......... 01 MED *CONCUSSION AGE 0-17... .2036 1.6 1.6 9
34.......... 01 MED OTHER DISORDERS OF 1.0639 4.6 6.5 29
NERVOUS SYSTEM W CC.
35.......... 01 MED OTHER DISORDERS OF .6112 3.2 4.3 27
NERVOUS SYSTEM.
W/O CC.................
36.......... 02 SURG RETINAL PROCEDURES.... .6156 1.3 1.6 6
37.......... 02 SURG ORBITAL PROCEDURES.... .9280 2.7 4.0 27
38.......... 02 SURG PRIMARY IRIS .4217 1.8 2.5 16
PROCEDURES.
39.......... 02 SURG LENS PROCEDURES WITH .5162 1.5 2.0 10
OR WITHOUT VITRECTOMY.
40.......... 02 SURG EXTRAOCULAR PROCEDURES .7094 2.2 3.4 26
EXCEPT ORBIT AGE >17.
41.......... 02 SURG *EXTRAOCULAR PROCEDURES .3298 1.6 1.6 7
EXCEPT ORBIT AGE 0-17.
42.......... 02 SURG INTRAOCULAR PROCEDURES .5821 1.6 2.2 13
EXCEPT RETINA, IRIS &
LENS.
43.......... 02 MED HYPHEMA............... .4448 3.2 4.1 27
[[Page 27532]]
44.......... 02 MED ACUTE MAJOR EYE .6234 4.7 5.7 29
INFECTIONS.
45.......... 02 MED NEUROLOGICAL EYE .6514 3.1 3.8 22
DISORDERS.
46.......... 02 MED OTHER DISORDERS OF THE .7595 4.0 5.5 28
EYE AGE >17 W CC.
47.......... 02 MED OTHER DISORDERS OF THE .4703 2.8 3.8 27
EYE AGE >17 W/O CC.
48.......... 02 MED *OTHER DISORDERS OF THE .2906 2.9 2.9 27
EYE AGE 0-17.
49.......... 03 SURG MAJOR HEAD & NECK 1.7253 4.1 5.6 28
PROCEDURES.
50.......... 03 SURG SIALOADENECTOMY....... .7677 1.7 2.1 9
51.......... 03 SURG SALIVARY GLAND .7358 1.9 3.0 21
PROCEDURES EXCEPT
SIALOADENECTOMY.
52.......... 03 SURG CLEFT LIP & PALATE 1.0971 2.1 3.6 26
REPAIR.
53.......... 03 SURG SINUS & MASTOID 1.0116 2.2 3.6 26
PROCEDURES AGE >17.
54.......... 03 SURG *SINUS & MASTOID .4711 3.2 3.2 22
PROCEDURES AGE 0-17.
55.......... 03 SURG MISCELLANEOUS EAR, .7844 1.9 3.0 22
NOSE, MOUTH & THROAT
PROCEDURES.
56.......... 03 SURG RHINOPLASTY........... .8247 2.1 2.8 18
57.......... 03 SURG T&A PROC, EXCEPT .9413 2.7 4.1 27
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE >17.
58.......... 03 SURG *T&A PROC, EXCEPT .2674 1.5 1.5 4
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 0-17.
59.......... 03 SURG TONSILLECTOMY &/OR .7521 2.3 3.7 26
ADENOIDECTOMY ONLY,
AGE >17.
60.......... 03 SURG *TONSILLECTOMY &/OR .2037 1.5 1.5 4
ADENOIDECTOMY ONLY,
AGE 0-17.
61.......... 03 SURG MYRINGOTOMY W TUBE 1.2155 2.7 5.3 27
INSERTION AGE >17.
62.......... 03 SURG *MYRINGOTOMY W TUBE .2884 1.3 1.3 5
INSERTION AGE 0-17.
63.......... 03 SURG OTHER EAR, NOSE, MOUTH 1.2217 3.2 4.7 27
& THROAT O.R.
PROCEDURES.
64.......... 03 MED EAR, NOSE, MOUTH & 1.1699 4.7 7.5 29
THROAT MALIGNANCY.
65.......... 03 MED DYSEQUILIBRIUM........ .5192 2.7 3.4 20
66.......... 03 MED EPISTAXIS............. .5358 2.9 3.6 21
67.......... 03 MED EPIGLOTTITIS.......... .8452 3.4 4.2 24
68.......... 03 MED OTITIS MEDIA & URI AGE .7075 3.8 4.8 27
>17 W CC.
69.......... 03 MED OTITIS MEDIA & URI AGE .5244 3.1 3.8 20
>17 W/O CC.
70.......... 03 MED OTITIS MEDIA & URI AGE .3839 2.6 3.1 15
0-17.
71.......... 03 MED LARYNGOTRACHEITIS..... .7959 3.1 4.2 27
72.......... 03 MED NASAL TRAUMA & .6466 3.1 4.4 27
DEFORMITY.
73.......... 03 MED OTHER EAR, NOSE, MOUTH .7483 3.7 5.0 28
& THROAT DIAGNOSES AGE
>17.
74.......... 03 MED *OTHER EAR, NOSE, MOUTH .3276 2.1 2.1 20
& THROAT DIAGNOSES AGE
0-17.
75.......... 04 SURG MAJOR CHEST PROCEDURES 3.1904 8.8 11.1 33
76.......... 04 SURG OTHER RESP SYSTEM O.R. 2.6018 9.1 12.5 33
PROCEDURES W CC.
77.......... 04 SURG OTHER RESP SYSTEM O.R. 1.1577 3.8 5.5 28
PROCEDURES W/O CC.
78.......... 04 MED PULMONARY EMBOLISM.... 1.4291 7.0 8.3 31
79.......... 04 MED RESPIRATORY INFECTIONS 1.6310 7.2 9.3 31
& INFLAMMATIONS AGE
>17 W CC.
80.......... 04 MED RESPIRATORY INFECTIONS .9481 5.4 6.6 29
& INFLAMMATIONS AGE
>17 W/O CC.
81.......... 04 MED *RESPIRATORY INFECTIONS .9716 6.1 6.1 30
& INFLAMMATIONS AGE 0-
17.
82.......... 04 MED RESPIRATORY NEOPLASMS. 1.3347 5.7 7.9 30
83.......... 04 MED MAJOR CHEST TRAUMA W .9738 4.9 6.4 29
CC.
84.......... 04 MED MAJOR CHEST TRAUMA W/O .5335 2.9 3.7 24
CC.
85.......... 04 MED PLEURAL EFFUSION W CC. 1.2229 5.6 7.4 30
86.......... 04 MED PLEURAL EFFUSION W/O .7175 3.4 4.5 27
CC.
87.......... 04 MED PULMONARY EDEMA & 1.3587 5.1 6.8 29
RESPIRATORY FAILURE.
88.......... 04 MED CHRONIC OBSTRUCTIVE .9831 4.9 6.1 29
PULMONARY DISEASE.
89.......... 04 MED SIMPLE PNEUMONIA & 1.1158 5.8 7.1 30
PLEURISY AGE >17 W CC.
90.......... 04 MED SIMPLE PNEUMONIA & .6995 4.3 5.1 24
PLEURISY AGE >17 W/O
CC.
91.......... 04 MED SIMPLE PNEUMONIA & .7883 3.7 4.7 28
PLEURISY AGE 0-17.
92.......... 04 MED INTERSTITIAL LUNG 1.2053 5.6 7.3 30
DISEASE W CC.
93.......... 04 MED INTERSTITIAL LUNG .7551 4.0 5.0 28
DISEASE W/O CC.
94.......... 04 MED PNEUMOTHORAX W CC..... 1.1764 5.3 7.1 29
95.......... 04 MED PNEUMOTHORAX W/O CC... .6035 3.3 4.1 25
96.......... 04 MED BRONCHITIS & ASTHMA .8254 4.5 5.5 29
AGE >17 W CC.
97.......... 04 MED BRONCHITIS & ASTHMA .6013 3.6 4.3 22
AGE >17 W/O CC.
98.......... 04 MED BRONCHITIS & ASTHMA .8036 3.1 4.5 27
AGE 0-17.
99.......... 04 MED RESPIRATORY SIGNS & .6868 2.7 3.5 22
SYMPTOMS W CC.
100......... 04 MED RESPIRATORY SIGNS & .5126 2.0 2.4 12
SYMPTOMS W/O CC.
101......... 04 MED OTHER RESPIRATORY .8735 3.8 5.2 28
SYSTEM DIAGNOSES W CC.
[[Page 27533]]
102......... 04 MED OTHER RESPIRATORY .5330 2.4 3.1 20
SYSTEM DIAGNOSES W/O
CC.
103......... 05 SURG HEART TRANSPLANT...... 15.2952 28.1 39.4 52
104......... 05 SURG CARDIAC VALVE 7.3389 12.0 14.6 36
PROCEDURES W CARDIAC
CATH.
105......... 05 SURG CARDIAC VALVE 5.6012 9.0 10.9 33
PROCEDURES W/O CARDIAC
CATH.
106......... 05 SURG CORONARY BYPASS W 5.5599 10.3 11.7 34
CARDIAC CATH.
107......... 05 SURG CORONARY BYPASS W/O 4.0741 7.8 8.8 32
CARDIAC CATH.
108......... 05 SURG OTHER CARDIOTHORACIC 5.9226 9.8 12.6 34
PROCEDURES.
109......... ....... ................ NO LONGER VALID........ .0000 .0 .0 0
110......... 05 SURG MAJOR CARDIOVASCULAR 4.1674 8.2 10.9 32
PROCEDURES W CC.
111......... 05 SURG MAJOR CARDIOVASCULAR 2.2863 5.9 6.7 30
PROCEDURES W/O CC.
112......... 05 SURG PERCUTANEOUS 2.0962 3.5 4.7 27
CARDIOVASCULAR
PROCEDURES.
113......... 05 SURG AMPUTATION FOR CIRC 2.6919 10.6 14.4 35
SYSTEM DISORDERS
EXCEPT UPPER LIMB &
TOE.
114......... 05 SURG UPPER LIMB & TOE 1.5122 6.8 9.5 31
AMPUTATION FOR CIRC
SYSTEM DISORDERS.
115......... 05 SURG PERM CARDIAC PACEMAKER 3.6844 9.1 11.4 33
IMPLANT W AMI, HEART
FAILURE OR SHOCK.
116......... 05 SURG OTH PERM CARDIAC 2.4158 3.9 5.4 28
PACEMAKER IMPLANT OR
AICD LEAD OR GENERATOR
PROC.
117......... 05 SURG CARDIAC PACEMAKER 1.1774 2.7 4.1 27
REVISION EXCEPT DEVICE
REPLACEMENT.
118......... 05 SURG CARDIAC PACEMAKER 1.5782 2.1 3.2 25
DEVICE REPLACEMENT.
119......... 05 SURG VEIN LIGATION & 1.1378 3.3 5.5 27
STRIPPING.
120......... 05 SURG OTHER CIRCULATORY 1.9321 5.4 9.2 29
SYSTEM O.R. PROCEDURES.
121......... 05 MED CIRCULATORY DISORDERS 1.6473 6.4 7.8 30
W AMI & C.V. COMP
DISCH ALIVE.
122......... 05 MED CIRCULATORY DISORDERS 1.1617 4.4 5.3 28
W AMI W/O C.V. COMP
DISCH ALIVE.
123......... 05 MED CIRCULATORY DISORDERS 1.4519 2.7 4.7 27
W AMI, EXPIRED.
124......... 05 MED CIRCULATORY DISORDERS 1.3264 3.8 5.0 28
EXCEPT AMI, W CARD
CATH & COMPLEX DIAG.
125......... 05 MED CIRCULATORY DISORDERS .9259 2.3 3.1 20
EXCEPT AMI, W CARD
CATH W/O COMPLEX DIAG.
126......... 05 MED ACUTE & SUBACUTE 2.5380 11.0 14.3 35
ENDOCARDITIS.
127......... 05 MED HEART FAILURE & SHOCK. 1.0268 4.8 6.2 29
128......... 05 MED DEEP VEIN .7861 5.9 6.7 27
THROMBOPHLEBITIS.
129......... 05 MED CARDIAC ARREST, 1.1239 2.0 3.4 26
UNEXPLAINED.
130......... 05 MED PERIPHERAL VASCULAR .9357 5.3 6.7 29
DISORDERS W CC.
131......... 05 MED PERIPHERAL VASCULAR .6045 4.3 5.2 28
DISORDERS W/O CC.
132......... 05 MED ATHEROSCLEROSIS W CC.. .6834 2.9 3.6 20
133......... 05 MED ATHEROSCLEROSIS W/O CC .5543 2.3 2.9 16
134......... 05 MED HYPERTENSION.......... .5799 3.0 3.9 23
135......... 05 MED CARDIAC CONGENITAL & .8797 3.7 5.0 28
VALVULAR DISORDERS AGE
>17 W CC.
136......... 05 MED CARDIAC CONGENITAL & .5597 2.6 3.2 18
VALVULAR DISORDERS AGE
>17 W/O CC.
137......... 05 MED *CARDIAC CONGENITAL & .7996 3.3 3.3 27
VALVULAR DISORDERS AGE
0-17.
138......... 05 MED CARDIAC ARRHYTHMIA & .8009 3.5 4.6 27
CONDUCTION DISORDERS W
CC.
139......... 05 MED CARDIAC ARRHYTHMIA & .4975 2.4 2.9 16
CONDUCTION DISORDERS W/
O CC.
140......... 05 MED ANGINA PECTORIS....... .6210 2.8 3.5 20
141......... 05 MED SYNCOPE & COLLAPSE W .7129 3.4 4.5 27
CC.
142......... 05 MED SYNCOPE & COLLAPSE W/O .5289 2.5 3.2 18
CC.
143......... 05 MED CHEST PAIN............ .5233 2.1 2.6 14
144......... 05 MED OTHER CIRCULATORY 1.0850 4.1 5.7 28
SYSTEM DIAGNOSES W CC.
145......... 05 MED OTHER CIRCULATORY .6217 2.5 3.3 20
SYSTEM DIAGNOSES W/O
CC.
146......... 06 SURG RECTAL RESECTION W CC. 2.6401 9.8 11.3 34
147......... 06 SURG RECTAL RESECTION W/O 1.6115 6.7 7.4 27
CC.
148......... 06 SURG MAJOR SMALL & LARGE 3.3693 11.2 13.4 35
BOWEL PROCEDURES W CC.
149......... 06 SURG MAJOR SMALL & LARGE 1.6038 7.1 7.7 25
BOWEL PROCEDURES W/O
CC.
150......... 06 SURG PERITONEAL 2.6786 9.5 11.7 34
ADHESIOLYSIS W CC.
151......... 06 SURG PERITONEAL 1.2959 5.2 6.5 29
ADHESIOLYSIS W/O CC.
152......... 06 SURG MINOR SMALL & LARGE 1.9381 7.6 9.0 32
BOWEL PROCEDURES W CC.
153......... 06 SURG MINOR SMALL & LARGE 1.1550 5.6 6.2 24
BOWEL PROCEDURES W/O
CC.
154......... 06 SURG STOMACH, ESOPHAGEAL & 4.1880 11.6 15.0 36
DUODENAL PROCEDURES
AGE >17 W CC.
[[Page 27534]]
155......... 06 SURG STOMACH, ESOPHAGEAL & 1.4070 4.6 5.9 29
DUODENAL PROCEDURES
AGE >17 W/O CC.
156......... 06 SURG *STOMACH, ESOPHAGEAL & .8235 6.0 6.0 30
DUODENAL PROCEDURES
AGE 0-17.
157......... 06 SURG ANAL & STOMAL 1.1331 4.2 5.8 28
PROCEDURES W CC.
158......... 06 SURG ANAL & STOMAL .6106 2.3 2.9 18
PROCEDURES W/O CC.
159......... 06 SURG HERNIA PROCEDURES 1.2263 4.0 5.3 28
EXCEPT INGUINAL &
FEMORAL AGE >17 W CC.
160......... 06 SURG HERNIA PROCEDURES .7032 2.4 3.0 16
EXCEPT INGUINAL &
FEMORAL AGE >17 W/O CC.
161......... 06 SURG INGUINAL & FEMORAL 1.0089 3.0 4.4 27
HERNIA PROCEDURES AGE
>17 W CC.
162......... 06 SURG INGUINAL & FEMORAL .5710 1.7 2.2 11
HERNIA PROCEDURES AGE
>17 W/O CC.
163......... 06 SURG *HERNIA PROCEDURES AGE .7703 2.1 2.1 11
0-17.
164......... 06 SURG APPENDECTOMY W 2.3299 8.0 9.3 32
COMPLICATED PRINCIPAL
DIAG W CC.
165......... 06 SURG APPENDECTOMY W 1.2576 5.1 5.8 25
COMPLICATED PRINCIPAL
DIAG W/O CC.
166......... 06 SURG APPENDECTOMY W/O 1.4512 4.5 5.7 29
COMPLICATED PRINCIPAL
DIAG W CC.
167......... 06 SURG APPENDECTOMY W/O .8496 2.8 3.2 15
COMPLICATED PRINCIPAL
DIAG W/O CC.
168......... 03 SURG MOUTH PROCEDURES W CC. 1.0951 3.2 4.9 27
169......... 03 SURG MOUTH PROCEDURES W/O .6828 2.0 2.6 15
CC.
170......... 06 SURG OTHER DIGESTIVE SYSTEM 2.7448 8.5 12.5 33
O.R. PROCEDURES W CC.
171......... 06 SURG OTHER DIGESTIVE SYSTEM 1.1297 4.0 5.4 28
O.R. PROCEDURES W/O CC.
172......... 06 MED DIGESTIVE MALIGNANCY W 1.2934 5.7 8.2 30
CC.
173......... 06 MED DIGESTIVE MALIGNANCY W/ .6736 3.0 4.3 27
O CC.
174......... 06 MED G.I. HEMORRHAGE W CC.. .9962 4.4 5.6 28
175......... 06 MED G.I. HEMORRHAGE W/O CC .5492 2.9 3.5 17
176......... 06 MED COMPLICATED PEPTIC 1.0874 4.7 6.2 29
ULCER.
177......... 06 MED UNCOMPLICATED PEPTIC .8353 4.0 5.0 28
ULCER W CC.
178......... 06 MED UNCOMPLICATED PEPTIC .6122 3.0 3.6 19
ULCER W/O CC.
179......... 06 MED INFLAMMATORY BOWEL 1.1219 5.5 7.2 30
DISEASE.
180......... 06 MED G.I. OBSTRUCTION W CC. .9202 4.7 6.1 29
181......... 06 MED G.I. OBSTRUCTION W/O .5346 3.3 4.0 22
CC.
182......... 06 MED ESOPHAGITIS, GASTROENT .7791 3.8 5.0 28
& MISC DIGEST
DISORDERS AGE >17 W CC.
183......... 06 MED ESOPHAGITIS, GASTROENT .5570 2.8 3.5 20
& MISC DIGEST
DISORDERS AGE >17 W/O
CC.
184......... 06 MED ESOPHAGITIS, GASTROENT .5366 2.7 3.8 26
& MISC DIGEST
DISORDERS AGE 0-17.
185......... 03 MED DENTAL & ORAL DIS .8467 3.7 5.2 28
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE >17.
186......... 03 MED *DENTAL & ORAL DIS .3139 2.9 2.9 23
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187......... 03 MED DENTAL EXTRACTIONS & .7211 3.1 4.3 27
RESTORATIONS.
188......... 06 MED OTHER DIGESTIVE SYSTEM 1.0593 4.5 6.1 28
DIAGNOSES AGE >17 W CC.
189......... 06 MED OTHER DIGESTIVE SYSTEM .5629 2.7 3.7 27
DIAGNOSES AGE >17 W/O
CC.
190......... 06 MED OTHER DIGESTIVE SYSTEM .8364 3.9 4.9 28
DIAGNOSES AGE 0-17.
191......... 07 SURG PANCREAS, LIVER & 4.4227 12.0 16.2 36
SHUNT PROCEDURES W CC.
192......... 07 SURG PANCREAS, LIVER & 1.8016 6.2 8.0 30
SHUNT PROCEDURES W/O
CC.
193......... 07 SURG BILIARY TRACT PROC 3.2582 11.4 13.9 35
EXCEPT ONLY CHOLECYST
W OR W/O C.D.E. W CC.
194......... 07 SURG BILIARY TRACT PROC 1.7596 6.8 8.4 31
EXCEPT ONLY CHOLECYST
W OR W/O C.D.E. W/O CC.
195......... 07 SURG CHOLECYSTECTOMY W 2.6806 8.8 10.5 33
C.D.E. W CC.
196......... 07 SURG CHOLECYSTECTOMY W 1.6252 5.9 6.8 30
C.D.E. W/O CC.
197......... 07 SURG CHOLECYSTECTOMY EXCEPT 2.2636 7.5 9.1 31
BY LAPAROSCOPE W/O
C.D.E. W CC.
198......... 07 SURG CHOLECYSTECTOMY EXCEPT 1.1769 4.3 5.0 23
BY LAPAROSCOPE W/O
C.D.E. W/O CC.
199......... 07 SURG HEPATOBILIARY 2.3744 8.3 11.1 32
DIAGNOSTIC PROCEDURE
FOR MALIGNANCY.
200......... 07 SURG HEPATOBILIARY 2.9783 7.6 11.9 32
DIAGNOSTIC PROCEDURE
FOR NON-MALIGNANCY.
[[Page 27535]]
201......... 07 SURG OTHER HEPATOBILIARY OR 3.6216 12.1 16.6 36
PANCREAS O.R.
PROCEDURES.
202......... 07 MED CIRRHOSIS & ALCOHOLIC 1.3286 5.7 7.7 30
HEPATITIS.
203......... 07 MED MALIGNANCY OF 1.2511 5.5 7.7 30
HEPATOBILIARY SYSTEM
OR PANCREAS.
204......... 07 MED DISORDERS OF PANCREAS 1.2003 5.1 6.7 29
EXCEPT MALIGNANCY.
205......... 07 MED DISORDERS OF LIVER 1.2099 5.3 7.3 29
EXCEPT MALIG,CIRR,ALC
HEPA W CC.
206......... 07 MED DISORDERS OF LIVER .7211 3.6 4.8 28
EXCEPT MALIG,CIRR,ALC
HEPA W/O CC.
207......... 07 MED DISORDERS OF THE 1.0500 4.4 5.8 28
BILIARY TRACT W CC.
208......... 07 MED DISORDERS OF THE .6053 2.6 3.5 21
BILIARY TRACT W/O CC.
209......... 08 SURG MAJOR JOINT & LIMB 2.2617 5.9 6.7 23
REATTACHMENT
PROCEDURES OF LOWER
EXTREMITY.
210......... 08 SURG HIP & FEMUR PROCEDURES 1.8458 7.2 8.5 31
EXCEPT MAJOR JOINT AGE
>17 W CC.
211......... 08 SURG HIP & FEMUR PROCEDURES 1.2747 5.6 6.3 23
EXCEPT MAJOR JOINT AGE
>17 W/O CC.
212......... 08 SURG *HIP & FEMUR PROCEDURES 1.1483 11.1 11.1 35
EXCEPT MAJOR JOINT AGE
0-17.
213......... 08 SURG AMPUTATION FOR 1.7045 7.0 9.6 31
MUSCULOSKELETAL SYSTEM
& CONN TISSUE
DISORDERS.
214......... 08 SURG BACK & NECK PROCEDURES 1.9259 4.9 6.5 29
W CC.
215......... 08 SURG BACK & NECK PROCEDURES 1.1135 3.0 3.7 20
W/O CC.
216......... 08 SURG BIOPSIES OF 2.0775 7.9 11.1 32
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE.
217......... 08 SURG WND DEBRID & SKN GRFT 2.8715 10.2 15.3 34
EXCEPT HAND,FOR
MUSCSKELET & CONN TISS
DIS.
218......... 08 SURG LOWER EXTREM & HUMER 1.4562 4.8 6.2 29
PROC EXCEPT HIP, FOOT,
FEMUR AGE >17 W CC.
219......... 08 SURG LOWER EXTREM & HUMER .9560 3.1 3.8 19
PROC EXCEPT HIP, FOOT,
FEMUR AGE >17 W/O CC.
220......... 08 SURG *LOWER EXTREM & HUMER .5704 5.3 5.3 29
PROC EXCEPT HIP, FOOT,
FEMUR AGE 0-17.
221......... 08 SURG KNEE PROCEDURES W CC.. 1.8379 5.8 8.2 30
222......... 08 SURG KNEE PROCEDURES W/O CC 1.0223 3.1 4.1 27
223......... 08 SURG MAJOR SHOULDER/ELBOW .8726 2.2 2.9 16
PROC, OR OTHER UPPER
EXTREMITY PROC W CC.
224......... 08 SURG SHOULDER,ELBOW OR .7418 1.9 2.3 10
FOREARM PROC,EXC MAJOR
JOINT PROC, W/O CC.
225......... 08 SURG FOOT PROCEDURES....... 1.0019 3.3 5.0 27
226......... 08 SURG SOFT TISSUE PROCEDURES 1.3708 4.4 6.7 28
W CC.
227......... 08 SURG SOFT TISSUE PROCEDURES .7458 2.3 3.0 18
W/O CC.
228......... 08 SURG MAJOR THUMB OR JOINT .9381 2.3 3.6 26
PROC, OR OTH HAND OR
WRIST PROC W CC.
229......... 08 SURG HAND OR WRIST PROC, .6495 1.8 2.4 14
EXCEPT MAJOR JOINT
PROC, W/O CC.
230......... 08 SURG LOCAL EXCISION & 1.0592 3.3 5.2 27
REMOVAL OF INT FIX
DEVICES OF HIP & FEMUR.
231......... 08 SURG LOCAL EXCISION & 1.2285 3.3 5.1 27
REMOVAL OF INT FIX
DEVICES EXCEPT HIP &
FEMUR.
232......... 08 SURG ARTHROSCOPY........... 1.0901 2.6 4.5 27
233......... 08 SURG OTHER MUSCULOSKELET 1.9951 6.4 9.0 30
SYS & CONN TISS O.R.
PROC W CC.
234......... 08 SURG OTHER MUSCULOSKELET 1.0684 3.1 4.2 27
SYS & CONN TISS O.R.
PROC W/O CC.
235......... 08 MED FRACTURES OF FEMUR.... .8353 4.6 6.9 29
236......... 08 MED FRACTURES OF HIP & .7613 4.7 6.4 29
PELVIS.
237......... 08 MED SPRAINS, STRAINS, & .5622 3.3 4.4 27
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238......... 08 MED OSTEOMYELITIS......... 1.3857 7.6 10.1 32
239......... 08 MED PATHOLOGICAL FRACTURES 1.0096 5.8 7.6 30
& MUSCULOSKELETAL &
CONN TISS MALIGNANCY.
240......... 08 MED CONNECTIVE TISSUE 1.2107 5.5 7.5 30
DISORDERS W CC.
241......... 08 MED CONNECTIVE TISSUE .6063 3.5 4.6 28
DISORDERS W/O CC.
242......... 08 MED SEPTIC ARTHRITIS...... 1.0535 5.8 7.7 30
243......... 08 MED MEDICAL BACK PROBLEMS. .7241 4.3 5.6 28
244......... 08 MED BONE DISEASES & .7221 4.3 5.8 28
SPECIFIC ARTHROPATHIES
W CC.
245......... 08 MED BONE DISEASES & .4965 3.2 4.2 27
SPECIFIC ARTHROPATHIES
W/O CC.
[[Page 27536]]
246......... 08 MED NON-SPECIFIC .5901 3.6 4.6 28
ARTHROPATHIES.
247......... 08 MED SIGNS & SYMPTOMS OF .5539 2.9 4.0 27
MUSCULOSKELETAL SYSTEM
& CONN TISSUE.
248......... 08 MED TENDONITIS, MYOSITIS & .7363 3.9 5.3 28
BURSITIS.
249......... 08 MED AFTERCARE, .6514 2.9 4.3 27
MUSCULOSKELETAL SYSTEM
& CONNECTIVE TISSUE.
250......... 08 MED FX, SPRN, STRN & DISL .6808 3.5 4.9 28
OF FOREARM, HAND, FOOT
AGE >17 W CC.
251......... 08 MED FX, SPRN, STRN & DISL .4625 2.5 3.3 22
OF FOREARM, HAND, FOOT
AGE >17 W/O CC.
252......... 08 MED *FX, SPRN, STRN & DISL .2478 1.8 1.8 15
OF FOREARM, HAND, FOOT
AGE 0-17.
253......... 08 MED FX, SPRN, STRN & DISL .7438 4.3 5.8 28
OF UPARM, LOWLEG EX
FOOT AGE >17 W CC.
254......... 08 MED FX, SPRN, STRN & DISL .4433 2.9 3.9 25
OF UPARM, LOWLEG EX
FOOT AGE >17 W/O CC.
255......... 08 MED *FX, SPRN, STRN & DISL .2885 2.9 2.9 27
OF UPARM, LOWLEG EX
FOOT AGE 0-17.
256......... 08 MED OTHER MUSCULOSKELETAL .7724 4.0 5.7 28
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES.
257......... 09 SURG TOTAL MASTECTOMY FOR .9021 2.8 3.4 17
MALIGNANCY W CC.
258......... 09 SURG TOTAL MASTECTOMY FOR .7099 2.2 2.5 10
MALIGNANCY W/O CC.
259......... 09 SURG SUBTOTAL MASTECTOMY .8673 2.3 3.5 26
FOR MALIGNANCY W CC.
260......... 09 SURG SUBTOTAL MASTECTOMY .6083 1.6 1.9 8
FOR MALIGNANCY W/O CC.
261......... 09 SURG BREAST PROC FOR NON- .8342 1.9 2.4 12
MALIGNANCY EXCEPT
BIOPSY & LOCAL
EXCISION.
262......... 09 SURG BREAST BIOPSY & LOCAL .7694 2.7 3.9 27
EXCISION FOR NON-
MALIGNANCY.
263......... 09 SURG SKIN GRAFT &/OR DEBRID 2.1157 9.8 13.9 34
FOR SKN ULCER OR
CELLULITIS W CC.
264......... 09 SURG SKIN GRAFT &/OR DEBRID 1.1308 6.0 8.4 30
FOR SKN ULCER OR
CELLULITIS W/O CC.
265......... 09 SURG SKIN GRAFT &/OR DEBRID 1.4949 4.8 7.7 29
EXCEPT FOR SKIN ULCER
OR CELLULITIS W CC.
266......... 09 SURG SKIN GRAFT &/OR DEBRID .7650 2.6 3.7 27
EXCEPT FOR SKIN ULCER
OR CELLULITIS W/O CC.
267......... 09 SURG PERIANAL & PILONIDAL .8086 2.7 4.1 27
PROCEDURES.
268......... 09 SURG SKIN, SUBCUTANEOUS .9935 2.5 4.0 27
TISSUE & BREAST
PLASTIC PROCEDURES.
269......... 09 SURG OTHER SKIN, SUBCUT 1.6361 6.2 9.1 30
TISS & BREAST PROC W
CC.
270......... 09 SURG OTHER SKIN, SUBCUT .7016 2.4 3.4 26
TISS & BREAST PROC W/O
CC.
271......... 09 MED SKIN ULCERS........... 1.0791 6.6 8.5 31
272......... 09 MED MAJOR SKIN DISORDERS W 1.0212 5.6 7.5 30
CC.
273......... 09 MED MAJOR SKIN DISORDERS W/ .6358 4.1 5.5 28
O CC.
274......... 09 MED MALIGNANT BREAST 1.0713 5.3 7.8 29
DISORDERS W CC.
275......... 09 MED MALIGNANT BREAST .4984 2.5 3.6 27
DISORDERS W/O CC.
276......... 09 MED NON-MALIGANT BREAST .6443 3.9 5.1 28
DISORDERS.
277......... 09 MED CELLULITIS AGE >17 W .8532 5.5 6.7 29
CC.
278......... 09 MED CELLULITIS AGE >17 W/O .5775 4.3 5.1 25
CC.
279......... 09 MED *CELLULITIS AGE 0-17... .7187 4.2 4.2 24
280......... 09 MED TRAUMA TO THE SKIN, .6765 3.7 5.1 28
SUBCUT TISS & BREAST
AGE >17 W CC.
281......... 09 MED TRAUMA TO THE SKIN, .4566 2.7 3.7 24
SUBCUT TISS & BREAST
AGE >17 W/O CC.
282......... 09 MED *TRAUMA TO THE SKIN, .2508 2.2 2.2 19
SUBCUT TISS & BREAST
AGE 0-17.
283......... 09 MED MINOR SKIN DISORDERS W .7034 4.1 5.5 28
CC.
284......... 09 MED MINOR SKIN DISORDERS W/ .4375 2.9 3.9 27
O CC.
285......... 10 SURG AMPUTAT OF LOWER LIMB 2.1948 9.5 13.5 34
FOR ENDOCRINE, NUTRIT,
& METABOL DISORDERS.
286......... 10 SURG ADRENAL & PITUITARY 2.3858 6.6 8.7 31
PROCEDURES.
287......... 10 SURG SKIN GRAFTS & WOUND 1.9722 9.4 13.4 33
DEBRID FOR ENDOC,
NUTRIT & METAB
DISORDERS.
288......... 10 SURG O.R. PROCEDURES FOR 2.0537 5.3 7.0 29
OBESITY.
289......... 10 SURG PARATHYROID PROCEDURES 1.0231 2.7 3.9 27
290......... 10 SURG THYROID PROCEDURES.... .8827 2.1 2.8 15
291......... 10 SURG THYROGLOSSAL .5221 1.4 1.8 8
PROCEDURES.
292......... 10 SURG OTHER ENDOCRINE, 2.6435 8.4 12.7 32
NUTRIT & METAB O.R.
PROC W CC.
[[Page 27537]]
293......... 10 SURG OTHER ENDOCRINE, 1.2415 4.4 6.4 28
NUTRIT & METAB O.R.
PROC W/O CC.
294......... 10 MED DIABETES AGE >35....... .7604 4.3 5.7 28
295......... 10 MED DIABETES AGE 0-35...... .7171 3.3 4.3 27
296......... 10 MED NUTRITIONAL & MISC .8939 4.7 6.4 29
METABOLIC DISORDERS
AGE >17 W CC.
297......... 10 MED NUTRITIONAL & MISC .5374 3.3 4.3 26
METABOLIC DISORDERS
AGE >17 W/O CC.
298......... 10 MED NUTRITIONAL & MISC .5036 2.3 3.0 19
METABOLIC DISORDERS
AGE 0-17.
299......... 10 MED INBORN ERRORS OF .8211 3.8 5.4 28
METABOLISM.
300......... 10 MED ENDOCRINE DISORDERS W 1.1005 5.5 7.3 30
CC.
301......... 10 MED ENDOCRINE DISORDERS W/O .6193 3.4 4.4 27
CC.
302......... 11 SURG KIDNEY TRANSPLANT...... 3.9210 10.4 12.3 34
303......... 11 SURG KIDNEY, URETER & MAJOR 2.6364 8.4 10.2 32
BLADDER PROCEDURES FOR
NEOPLASM.
304......... 11 SURG KIDNEY, URETER & MAJOR 2.3744 7.5 10.3 31
BLADDER PROC FOR NON-
NEOPL W CC.
305......... 11 SURG KIDNEY, URETER & MAJOR 1.1797 3.9 4.9 28
BLADDER PROC FOR NON-
NEOPL W/O CC.
306......... 11 SURG PROSTATECTOMY W CC.... 1.2243 4.3 6.2 28
307......... 11 SURG PROSTATECTOMY W/O CC.. .6709 2.4 3.0 15
308......... 11 SURG MINOR BLADDER 1.5260 4.6 7.0 29
PROCEDURES W CC.
309......... 11 SURG MINOR BLADDER .8858 2.3 3.0 18
PROCEDURES W/O CC.
310......... 11 SURG TRANSURETHRAL 1.0013 3.1 4.6 27
PROCEDURES W CC.
311......... 11 SURG TRANSURETHRAL .5663 1.8 2.2 11
PROCEDURES W/O CC.
312......... 11 SURG URETHRAL PROCEDURES, .9118 3.1 4.8 27
AGE >17 W CC.
313......... 11 SURG URETHRAL PROCEDURES, .5211 1.7 2.3 13
AGE >17 W/O CC.
314......... 11 SURG *URETHRAL PROCEDURES, .4835 2.3 2.3 26
AGE 0-17.
315......... 11 SURG OTHER KIDNEY & URINARY 2.0606 5.3 9.3 29
TRACT O.R. PROCEDURES.
316......... 11 MED RENAL FAILURE......... 1.3066 5.4 7.6 29
317......... 11 MED ADMIT FOR RENAL .4837 2.0 2.8 19
DIALYSIS.
318......... 11 MED KIDNEY & URINARY TRACT 1.1233 5.0 7.2 29
NEOPLASMS W CC.
319......... 11 MED KIDNEY & URINARY TRACT .5801 2.3 3.2 24
NEOPLASMS W/O CC.
320......... 11 MED KIDNEY & URINARY TRACT .9052 5.1 6.4 29
INFECTIONS AGE >17 W
CC.
321......... 11 MED KIDNEY & URINARY TRACT .6094 3.9 4.7 24
INFECTIONS AGE >17 W/O
CC.
322......... 11 MED KIDNEY & URINARY TRACT .5265 3.6 4.4 24
INFECTIONS AGE 0-17.
323......... 11 MED URINARY STONES W CC, &/ .7490 2.7 3.6 24
OR ESW LITHOTRIPSY.
324......... 11 MED URINARY STONES W/O CC. .4161 1.7 2.1 10
325......... 11 MED KIDNEY & URINARY TRACT .6397 3.4 4.6 27
SIGNS & SYMPTOMS AGE
>17 W CC.
326......... 11 MED KIDNEY & URINARY TRACT .4346 2.4 3.5 19
SIGNS & SYMPTOMS AGE
>17 W/O CC.
327......... 11 MED *KIDNEY & URINARY TRACT .2340 3.1 3.1 27
SIGNS & SYMPTOMS AGE 0-
17.
328......... 11 MED URETHRAL STRICTURE AGE .6929 3.1 4.3 27
>17 W CC.
329......... 11 MED URETHRAL STRICTURE AGE .4536 2.1 2.8 16
>17 W/O CC.
330......... 11 MED *URETHRAL STRICTURE AGE .3114 1.6 1.6 9
0-17.
331......... 11 MED OTHER KIDNEY & URINARY .9926 4.6 6.2 29
TRACT DIAGNOSES AGE
>17 W CC.
332......... 11 MED OTHER KIDNEY & URINARY .6170 2.8 3.9 27
TRACT DIAGNOSES AGE
>17 W/O CC.
333......... 11 MED OTHER KIDNEY & URINARY .8641 4.3 5.9 28
TRACT DIAGNOSES AGE 0-
17.
334......... 12 SURG MAJOR MALE PELVIC 1.6656 5.3 6.0 23
PROCEDURES W CC.
335......... 12 SURG MAJOR MALE PELVIC 1.2596 4.1 4.6 17
PROCEDURES W/O CC.
336......... 12 SURG TRANSURETHRAL .8859 3.2 4.1 24
PROSTATECTOMY W CC.
337......... 12 SURG TRANSURETHRAL .6149 2.3 2.7 11
PROSTATECTOMY W/O CC.
338......... 12 SURG TESTES PROCEDURES, FOR 1.0534 3.5 5.3 27
MALIGNANCY.
339......... 12 SURG TESTES PROCEDURES, NON- 1.0213 3.1 4.9 27
MALIGNANCY AGE >17.
340......... 12 SURG *TESTES PROCEDURES, NON- .2768 2.4 2.4 13
MALIGNANCY AGE 0-17.
341......... 12 SURG PENIS PROCEDURES...... 1.0701 2.3 3.2 21
342......... 12 SURG CIRCUMCISION AGE >17.. .7579 2.6 4.0 27
343......... 12 SURG *CIRCUMCISION AGE 0-17. .1503 1.7 1.7 6
344......... 12 SURG OTHER MALE 1.0086 2.3 3.5 25
REPRODUCTIVE SYSTEM
O.R. PROCEDURES FOR
MALIGNANCY.
345......... 12 SURG OTHER MALE .8396 2.7 4.0 27
REPRODUCTIVE SYSTEM
O.R. PROC EXCEPT FOR
MALIGNANCY.
[[Page 27538]]
346......... 12 MED MALIGNANCY, MALE .9564 4.8 6.8 29
REPRODUCTIVE SYSTEM, W
CC.
347......... 12 MED MALIGNANCY, MALE .5161 2.4 3.4 26
REPRODUCTIVE SYSTEM, W/
O CC.
348......... 12 MED BENIGN PROSTATIC .7102 3.5 4.9 28
HYPERTROPHY W CC.
349......... 12 MED BENIGN PROSTATIC .4048 2.2 3.0 21
HYPERTROPHY W/O CC.
350......... 12 MED INFLAMMATION OF THE .6631 3.9 4.8 24
MALE REPRODUCTIVE
SYSTEM.
351......... 12 MED *STERILIZATION, MALE... .2309 1.3 1.3 5
352......... 12 MED OTHER MALE .5889 2.8 4.0 27
REPRODUCTIVE SYSTEM
DIAGNOSES.
353......... 13 SURG PELVIC EVISCERATION, 1.9266 6.7 8.4 31
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354......... 13 SURG UTERINE, ADNEXA PROC 1.4646 5.2 6.3 28
FOR NON-OVARIAN/
ADNEXAL MALIG W CC.
355......... 13 SURG UTERINE, ADNEXA PROC .9065 3.6 3.9 11
FOR NON-OVARIAN/
ADNEXAL MALIG W/O CC.
356......... 13 SURG FEMALE REPRODUCTIVE .7377 2.6 3.0 12
SYSTEM RECONSTRUCTIVE
PROCEDURES.
357......... 13 SURG UTERINE & ADNEXA PROC 2.3847 8.0 9.8 32
FOR OVARIAN OR ADNEXAL
MALIGNANCY.
358......... 13 SURG UTERINE & ADNEXA PROC 1.1713 4.0 4.7 19
FOR NON-MALIGNANCY W
CC.
359......... 13 SURG UTERINE & ADNEXA PROC .8289 3.0 3.3 10
FOR NON-MALIGNANCY W/O
CC.
360......... 13 SURG VAGINA, CERVIX & VULVA .8470 2.9 3.5 17
PROCEDURES.
361......... 13 SURG LAPAROSCOPY & 1.1284 2.5 3.5 23
INCISIONAL TUBAL
INTERRUPTION.
362......... 13 SURG *ENDOSCOPIC TUBAL .2950 1.4 1.4 5
INTERRUPTION.
363......... 13 SURG D&C, CONIZATION & .6887 2.6 3.5 20
RADIO-IMPLANT, FOR
MALIGNANCY.
364......... 13 SURG D&C, CONIZATION EXCEPT .6823 2.6 3.6 27
FOR MALIGNANCY.
365......... 13 SURG OTHER FEMALE 1.7253 5.3 8.1 29
REPRODUCTIVE SYSTEM
O.R. PROCEDURES.
366......... 13 MED MALIGNANCY, FEMALE 1.1948 5.3 7.7 29
REPRODUCTIVE SYSTEM W
CC.
367......... 13 MED MALIGNANCY, FEMALE .5173 2.3 3.3 24
REPRODUCTIVE SYSTEM W/
O CC.
368......... 13 MED INFECTIONS, FEMALE 1.0303 5.3 6.9 29
REPRODUCTIVE SYSTEM.
369......... 13 MED MENSTRUAL & OTHER .5504 2.6 3.8 27
FEMALE REPRODUCTIVE
SYSTEM DISORDERS.
370......... 14 SURG CESAREAN SECTION W CC. 1.0444 4.3 5.6 26
371......... 14 SURG CESAREAN SECTION W/O .6865 3.2 3.6 11
CC.
372......... 14 MED VAGINAL DELIVERY W .5471 2.4 3.3 19
COMPLICATING DIAGNOSES.
373......... 14 MED VAGINAL DELIVERY W/O .3584 1.6 1.9 7
COMPLICATING DIAGNOSES.
374......... 14 SURG VAGINAL DELIVERY W .6083 2.0 2.4 9
STERILIZATION &/OR D&C.
375......... 14 SURG *VAGINAL DELIVERY W .6696 4.4 4.4 28
O.R. PROC EXCEPT
STERIL &/OR D&C.
376......... 14 MED POSTPARTUM & POST .5972 2.4 3.5 26
ABORTION DIAGNOSES W/O
O.R. PROCEDURE.
377......... 14 SURG POSTPARTUM & POST .8078 2.0 3.2 26
ABORTION DIAGNOSES W
O.R. PROCEDURE.
378......... 14 MED ECTOPIC PREGNANCY..... .8157 2.5 3.0 15
379......... 14 MED THREATENED ABORTION... .3573 2.0 2.9 20
380......... 14 MED ABORTION W/O D&C...... .4988 1.8 2.3 13
381......... 14 SURG ABORTION W D&C, .5212 1.6 2.3 14
ASPIRATION CURETTAGE
OR HYSTEROTOMY.
382......... 14 MED FALSE LABOR........... .2100 1.3 1.7 7
383......... 14 MED OTHER ANTEPARTUM .4672 2.8 4.1 27
DIAGNOSES W MEDICAL
COMPLICATIONS.
384......... 14 MED OTHER ANTEPARTUM .4140 1.9 3.3 24
DIAGNOSES W/O MEDICAL
COMPLICATIONS.
385......... 15 ................ *NEONATES, DIED OR 1.3437 1.8 1.8 26
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386......... 15 ................ *EXTREME IMMATURITY OR 4.4311 17.9 17.9 42
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387......... 15 ................ *PREMATURITY W MAJOR 3.0264 13.3 13.3 37
PROBLEMS.
388......... 15 ................ *PREMATURITY W/O MAJOR 1.8261 8.6 8.6 33
PROBLEMS.
389......... 15 FULL TERM NEONATE W 2.2247 8.0 10.7 32
MAJOR PROBLEMS.
390......... 15 NEONATE W OTHER 1.4188 3.8 5.0 28
SIGNIFICANT PROBLEMS.
391......... 15 ................ *NORMAL NEWBORN........ .1489 3.1 3.1 11
392......... 16 SURG SPLENECTOMY AGE >17... 3.2602 8.9 11.7 33
393......... 16 SURG *SPLENECTOMY AGE 0-17.. 1.3163 9.1 9.1 33
[[Page 27539]]
394......... 16 SURG OTHER O.R. PROCEDURES 1.5902 4.5 7.9 28
OF THE BLOOD AND BLOOD
FORMING ORGANS.
395......... 16 MED RED BLOOD CELL .8360 3.9 5.4 28
DISORDERS AGE >17.
396......... 16 MED RED BLOOD CELL .7226 2.8 3.9 27
DISORDERS AGE 0-17.
397......... 16 MED COAGULATION DISORDERS. 1.2574 4.4 6.1 28
398......... 16 MED RETICULOENDOTHELIAL & 1.2106 5.2 6.6 29
IMMUNITY DISORDERS W
CC.
399......... 16 MED RETICULOENDOTHELIAL & .7061 3.5 4.4 27
IMMUNITY DISORDERS W/O
CC.
400......... 17 SURG LYMPHOMA & LEUKEMIA W 2.5606 6.6 10.3 31
MAJOR O.R. PROCEDURE.
401......... 17 SURG LYMPHOMA & NON-ACUTE 2.4945 8.5 12.4 32
LEUKEMIA W OTHER O.R.
PROC W CC.
402......... 17 SURG LYMPHOMA & NON-ACUTE 1.0299 3.1 4.7 27
LEUKEMIA W OTHER O.R.
PROC W/O CC.
403......... 17 MED LYMPHOMA & NON-ACUTE 1.6925 6.5 9.3 30
LEUKEMIA W CC.
404......... 17 MED LYMPHOMA & NON-ACUTE .8070 3.7 5.1 28
LEUKEMIA W/O CC.
405......... 17 ................ *ACUTE LEUKEMIA W/O 1.8661 4.9 4.9 29
MAJOR O.R. PROCEDURE
AGE 0-17.
406......... 17 SURG MYELOPROLIF DISORD OR 2.6923 8.1 11.2 32
POORLY DIFF NEOPL W
MAJ O.R. PROC W CC.
407......... 17 SURG MYELOPROLIF DISORD OR 1.1822 3.8 4.9 28
POORLY DIFF NEOPL W
MAJ O.R. PROC W/O CC.
408......... 17 SURG MYELOPROLIF DISORD OR 1.7412 5.0 8.2 29
POORLY DIFF NEOPL W
OTHER O.R. PROC.
409......... 17 MED RADIOTHERAPY.......... .9708 4.7 6.7 29
410......... 17 MED CHEMOTHERAPY W/O ACUTE .7524 2.6 3.4 20
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411......... 17 MED HISTORY OF MALIGNANCY .3780 2.1 2.6 14
W/O ENDOSCOPY.
412......... 17 MED HISTORY OF MALIGNANCY .4133 2.2 3.1 24
W ENDOSCOPY.
413......... 17 MED OTHER MYELOPROLIF DIS 1.3263 5.9 8.3 30
OR POORLY DIFF NEOPL
DIAG W CC.
414......... 17 MED OTHER MYELOPROLIF DIS .7442 3.8 5.2 28
OR POORLY DIFF NEOPL
DIAG W/O CC.
415......... 18 SURG O.R. PROCEDURE FOR 3.4473 11.4 15.7 35
INFECTIOUS & PARASITIC
DISEASES.
416......... 18 MED SEPTICEMIA AGE >17.... 1.4862 6.2 8.2 30
417......... 18 MED SEPTICEMIA AGE 0-17... .7936 3.7 4.7 28
418......... 18 MED POSTOPERATIVE & POST- .9678 5.3 6.8 29
TRAUMATIC INFECTIONS.
419......... 18 MED FEVER OF UNKNOWN .8993 4.4 5.7 28
ORIGIN AGE >17 W CC.
420......... 18 MED FEVER OF UNKNOWN .6253 3.5 4.3 24
ORIGIN AGE >17 W/O CC.
421......... 18 MED VIRAL ILLNESS AGE >17. .7157 3.6 4.6 28
422......... 18 MED VIRAL ILLNESS & FEVER .5217 2.9 3.7 23
OF UNKNOWN ORIGIN AGE
0-17.
423......... 18 MED OTHER INFECTIOUS & 1.5864 6.3 8.7 30
PARASITIC DISEASES
DIAGNOSES.
424......... 19 SURG O.R. PROCEDURE W 2.3596 10.9 17.8 35
PRINCIPAL DIAGNOSES OF
MENTAL ILLNESS.
425......... 19 MED ACUTE ADJUST REACT & .7078 3.5 4.9 27
DISTURBANCES OF
PSYCHOSOCIAL
DYSFUNCTION.
426......... 19 MED DEPRESSIVE NEUROSES... .5715 4.0 5.5 28
427......... 19 MED NEUROSES EXCEPT .5544 3.7 5.3 28
DEPRESSIVE.
428......... 19 MED DISORDERS OF .7352 5.2 8.5 29
PERSONALITY & IMPULSE
CONTROL.
429......... 19 MED ORGANIC DISTURBANCES & .9063 5.9 8.9 30
MENTAL RETARDATION.
430......... 19 MED PSYCHOSES............. .8422 6.9 9.8 31
431......... 19 MED CHILDHOOD MENTAL .6694 5.0 7.5 29
DISORDERS.
432......... 19 MED OTHER MENTAL DISORDER .7228 3.9 6.3 28
DIAGNOSES.
433......... 20 ................ ALCOHOL/DRUG ABUSE OR .3007 2.5 3.4 24
DEPENDENCE, LEFT AMA.
434......... 20 ................ ALC/DRUG ABUSE OR .7152 4.4 5.8 28
DEPEND, DETOX OR OTH
SYMPT TREAT W CC.
435......... 20 ................ ALC/DRUG ABUSE OR .4178 3.8 4.8 28
DEPEND, DETOX OR OTH
SYMPT TREAT W/O CC.
436......... 20 ................ ALC/DRUG DEPENDENCE W .8199 12.1 14.8 36
REHABILITATION THERAPY.
437......... 20 ................ ALC/DRUG DEPENDENCE, .7714 9.2 10.9 33
COMBINED REHAB & DETOX
THERAPY.
438......... ....... ................ NO LONGER VALID........ .0000 .0 .0 0
439......... 21 SURG SKIN GRAFTS FOR 1.6153 5.8 8.9 30
INJURIES.
440......... 21 SURG WOUND DEBRIDEMENTS FOR 1.7631 6.3 9.8 30
INJURIES.
441......... 21 SURG HAND PROCEDURES FOR .9344 2.4 4.4 26
INJURIES.
442......... 21 SURG OTHER O.R. PROCEDURES 2.1659 5.6 8.7 30
FOR INJURIES W CC.
[[Page 27540]]
443......... 21 SURG OTHER O.R. PROCEDURES .8851 2.5 3.5 26
FOR INJURIES W/O CC.
444......... 21 MED TRAUMATIC INJURY AGE .7310 4.0 5.3 28
>17 W CC.
445......... 21 MED TRAUMATIC INJURY AGE .4754 2.8 3.8 24
>17 W/O CC.
446......... 21 MED *TRAUMATIC INJURY AGE 0- .2893 2.4 2.4 22
17.
447......... 21 MED ALLERGIC REACTIONS AGE .4908 2.1 2.8 17
>17.
448......... 21 MED ALLERGIC REACTIONS AGE .0759 1.0 1.0 1
0-17.
449......... 21 MED POISONING & TOXIC .7907 3.0 4.4 27
EFFECTS OF DRUGS AGE
>17 W CC.
450......... 21 MED POISONING & TOXIC .4276 1.8 2.3 13
EFFECTS OF DRUGS AGE
>17 W/O CC.
451......... 21 MED *POISONING & TOXIC .2569 2.1 2.1 17
EFFECTS OF DRUGS AGE 0-
17.
452......... 21 MED COMPLICATIONS OF .9448 3.8 5.4 28
TREATMENT W CC.
453......... 21 MED COMPLICATIONS OF .4853 2.4 3.2 20
TREATMENT W/O CC.
454......... 21 MED OTHER INJURY, .8536 3.4 5.1 27
POISONING & TOXIC
EFFECT DIAG W CC.
455......... 21 MED OTHER INJURY, .4445 2.1 2.8 18
POISONING & TOXIC
EFFECT DIAG W/O CC.
456......... 22 ................ BURNS, TRANSFERRED TO 1.8816 4.0 8.4 28
ANOTHER ACUTE CARE
FACILITY.
457......... 22 MED EXTENSIVE BURNS W/O 1.4446 2.4 4.8 26
O.R. PROCEDURE.
458......... 22 SURG NON-EXTENSIVE BURNS W 3.5465 12.0 17.0 36
SKIN GRAFT.
459......... 22 SURG NON-EXTENSIVE BURNS W 1.6693 6.7 10.3 31
WOUND DEBRIDEMENT OR
OTHER O.R. PROC.
460......... 22 MED NON-EXTENSIVE BURNS W/ .9554 4.6 6.6 29
O O.R. PROCEDURE.
461......... 23 SURG O.R. PROC W DIAGNOSES .9981 2.5 4.9 27
OF OTHER CONTACT W
HEALTH SERVICES.
462......... 23 MED REHABILITATION........ 1.4294 11.0 14.0 35
463......... 23 MED SIGNS & SYMPTOMS W CC. .7074 3.8 5.2 28
464......... 23 MED SIGNS & SYMPTOMS W/O .5040 2.8 3.7 24
CC.
465......... 23 MED AFTERCARE W HISTORY OF .5611 2.3 3.9 26
MALIGNANCY AS
SECONDARY DIAGNOSIS.
466......... 23 MED AFTERCARE W/O HISTORY .5728 2.5 4.7 27
OF MALIGNANCY AS
SECONDARY DIAGNOSIS.
467......... 23 MED OTHER FACTORS .4588 2.4 4.1 26
INFLUENCING HEALTH
STATUS.
468......... ....... ................ EXTENSIVE O.R. 3.5858 10.6 15.3 35
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
469......... ....... ................ **PRINCIPAL DIAGNOSIS .0000 .0 .0 0
INVALID AS DISCHARGE
DIAGNOSIS.
470......... ....... ................ **UNGROUPABLE.......... .0000 .0 .0 0
471......... 08 SURG BILATERAL OR MULTIPLE 3.6043 6.8 8.0 31
MAJOR JOINT PROCS OF
LOWER EXTREMITY.
472......... 22 SURG EXTENSIVE BURNS W O.R. 11.1357 17.3 30.7 41
PROCEDURE.
473......... 17 ................ ACUTE LEUKEMIA W/O 3.5669 8.5 14.7 32
MAJOR O.R. PROCEDURE
AGE >17.
474......... ....... ................ NO LONGER VALID........ .0000 .0 .0 0
475......... 04 MED RESPIRATORY SYSTEM 3.6736 8.6 12.3 33
DIAGNOSIS WITH
VENTILATOR SUPPORT.
476......... ....... SURG PROSTATIC O.R. 2.2362 10.3 13.8 34
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
477......... ....... SURG NON-EXTENSIVE O.R. 1.7153 5.8 9.2 30
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478......... 05 SURG OTHER VASCULAR 2.2890 5.6 8.3 30
PROCEDURES W CC.
479......... 05 SURG OTHER VASCULAR 1.4113 3.5 4.6 27
PROCEDURES W/O CC.
480......... ....... SURG LIVER TRANSPLANT....... 12.8388 22.5 29.7 47
481......... ....... SURG BONE MARROW TRANSPLANT. 11.2985 29.1 32.1 53
482......... ....... SURG TRACHEOSTOMY FOR FACE, 3.6598 11.4 15.0 35
MOUTH & NECK DIAGNOSES.
483......... ....... SURG TRACHEOSTOMY EXCEPT FOR 16.0114 35.9 46.2 60
FACE, MOUTH & NECK
DIAGNOSES.
484......... 24 SURG CRANIOTOMY FOR 5.5711 10.4 15.5 34
MULTIPLE SIGNIFICANT
TRAUMA.
485......... 24 SURG LIMB REATTACHMENT, HIP 3.1619 9.1 11.6 33
AND FEMUR PROC FOR
MULTIPLE SIGNIFICANT
TR.
486......... 24 SURG OTHER O.R. PROCEDURES 4.8009 9.0 13.5 33
FOR MULTIPLE
SIGNIFICANT TRAUMA.
487......... 24 MED OTHER MULTIPLE 1.9999 6.1 9.0 30
SIGNIFICANT TRAUMA.
488......... 25 SURG HIV W EXTENSIVE O.R. 4.2773 12.9 17.6 37
PROCEDURE.
489......... 25 MED HIV W MAJOR RELATED 1.7436 7.0 10.4 31
CONDITION.
490......... 25 MED HIV W OR W/O OTHER 1.0106 4.4 6.6 28
RELATED CONDITION.
491......... 08 SURG MAJOR JOINT & LIMB 1.6358 3.6 4.3 19
REATTACHMENT
PROCEDURES OF UPPER
EXTREMITY.
[[Page 27541]]
492......... 17 MED CHEMOTHERAPY W ACUTE 4.0624 11.2 17.4 35
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493......... 07 SURG LAPAROSCOPIC 1.7085 4.2 5.9 28
CHOLECYSTECTOMY W/O
C.D.E. W CC.
494......... 07 SURG LAPAROSCOPIC .9186 1.8 2.4 15
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
495......... ....... SURG LUNG TRANSPLANT........ 9.8070 18.4 23.8 42
----------------------------------------------------------------------------------------------------------------
*Medicare data have been supplemented by data from 19 states for low volume DRGS.
**DRGS 469 and 470 contain cases which could not be assigned to valid DRGS.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is used only to determine payment for outlier cases.
Note: relative weights are based on Medicare patient data and may not be appropriate for other patients.
Table 6a.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
079.6....... Respiratory syncytial virus N 15 387\1\, 389 \1\
(RSV).
18 421, 422
291.81...... Alcohol withdrawal.......... Y 20 434, 435, 436, 437
291.89...... Other specified alcoholic Y 20 434, 435, 436, 437
psychosis, not elsewhere
classified.
293.84...... Organic anxiety syndrome.... Y 19 429
300.82...... Undifferentiated somatoform N 19 427
disorder.
315.32...... Receptive language disorder N 19 431
(mixed).
414.04...... Coronary atherosclerosis of N 5 132, 133
artery bypass graft.
414.05...... Coronary atherosclerosis of N 5 132, 133
unspecified type of bypass
graft.
466.11...... Acute bronchiolitis due to N 4 96, 97, 98
respiratory syncytial virus
(RSV).
466.19...... Acute bronchiolitis due to N 4 96, 97, 98
other infectious organisms.
483.1....... Pneumonia due to Chlamydia.. Y 4 89, 90, 91
15 387,\1\ 389\1\
574.60...... Calculus of gallbladder and Y 7 207, 208
bile duct with acute
cholecystitis without
mention of obstruction.
574.61...... Calculus of gallbladder and Y 7 207, 208
bile duct with acute
cholecystitis with
obstruction.
574.70...... Calculus of gallbladder and Y 7 207, 208
bile duct with other
cholecystitis without
mention of obstruction.
574.71...... Calculus of gallbladder and Y 7 207, 208
bile duct with other
cholecystitis with
obstruction.
574.80...... Calculus of gallbladder and Y 7 207, 208
bile duct with acute and
chronic cholecystitis
without mention of
obstruction.
574.81...... Calculus of gallbladder and Y 7 207, 208
bile duct with acute and
chronic cholecystitis with
obstruction.
574.90...... Calculus of gallbladder and Y 7 207, 208
bile duct without
cholecystitis without
mention of obstruction.
574.91...... Calculus of gallbladder and Y 7 207, 208
bile duct without
cholecystitis with
obstruction.
575.10...... Cholecystitis, unspecified.. N 7 207, 208
575.11...... Chronic cholecystitis....... N 7 207, 208
575.12...... Acute and chronic Y 7 207, 208
cholecystitis.
752.51...... Undescended testis.......... N 12 352
752.52...... Retractile testis........... N 12 352
752.61...... Hypospadias................. N 12 352
752.62...... Epispadias.................. N 12 352
752.63...... Congenital chordee.......... N 12 352
752.64...... Micropenis.................. N 12 352
752.65...... Hidden penis................ N 12 352
752.69...... Other penile anomalies...... N 12 352
753.20...... Unspecified obstructive N 11 331, 332, 333
defect of renal pelvis and
ureter.
753.21...... Congenital obstruction of N 11 331, 332, 333
ureteropelvic junction.
753.22...... Congenital obstruction of N 11 331, 332, 333
ureterovesical junction.
753.23...... Congenital ureterocele...... N 11 331, 332, 333
753.29...... Obstructive defects of renal N 11 331, 332, 333
pelvis and ureter, not
elsewhere classifed.
758.81...... Other conditions due to sex N 12 352
chromosome anomalies.
13 358, 359, 369
758.89...... Other conditions due to N 12 352
chromosome anomalies, not
elsewhere classified.
13 358, 359, 369
922.31...... Back contusion.............. N 9 280, 281, 282
922.32...... Buttock contusion........... N 9 280, 281, 282
922.33...... Interscapular region N 9 280, 281, 282
contusion.
995.50...... Child abuse, unspecified.... N 21 454, 455
995.51...... Child emotional/ N 21 454, 455
psychological abuse.
[[Page 27542]]
995.52...... Child neglect (nutritional). N 21 454, 455
995.53...... Child sexual abuse.......... N 21 454, 455
995.54...... Child physical abuse........ N 21 454, 455
995.55...... Shaken infant syndrome...... N 21 454, 455
995.59...... Child maltreatment syndrome, N 21 454, 455
not elsewhere classified.
995.80...... Adult maltreatment, N 21 454, 455
unspecified.
995.82...... Adult emotional/ N 21 454, 455
psychological abuse.
995.83...... Adult sexual abuse.......... N 21 454, 455
995.84...... Adult neglect (nutritional). N 21 454, 455
995.85...... Other adult abuse and N 21 454, 455
neglect.
998.11...... Hemorrhage complicating a Y 21 452, 453
procedure.
998.12...... Hematoma complicating a Y 21 452, 453
procedure.
998.13...... Seroma complicating a Y 21 452, 453
procedure.
998.51...... Infected postoperative Y 18 418
seroma.
998.59...... Other postoperative Y 18 418
infection.
998.83...... Non-healing surgical wound.. Y 21 452, 453
V15.41...... History of physical abuse... N 23 467
V15.42...... History of emotional abuse.. N 23 467
V15.49...... Psychological trauma, not N 23 467
elsewhere classified.
V61.10...... Counseling for marital and N 23 467
partner problems,
unspecified.
V61.11...... Counseling for victim of N 23 467
spousal and partner abuse.
V61.12...... Counseling for perpetrator N 23 467
of spousal and partner
abuse.
V61.22...... Counseling for perpetrator N 23 467
of parental child abuse.
V62.83...... Counseling for perpetrator N 23 467
of physical/sexual abuse.
V66.7....... Encounter for palliative N 23 467
care.
----------------------------------------------------------------------------------------------------------------
\1\ Diagnosis code is classified as a ``major problem'' in these DRGs.
Table 6b.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
36.17...... Abdominal-coronary artery Y 5 106, 107
bypass.
39.90...... Insertion of non-coronary N .......... ..................................
artery stent or stents.
47.01...... Laparoscopic appendectomy.... Y 6 164, 165, 166, 167
47.09...... Other appendectomy........... Y 6 164, 165, 166, 167
47.11...... Laparoscopic incidental Y 13 365
appendectomy.
21 442, 443
24 486
47.19...... Other incidental appendectomy Y 13 365
21 442, 443
24 486
51.21...... Other partial cholecystectomy Y 7 193, 194
17 400, 406,
17 407
21 442, 443
24 486
51.24...... Laparoscopic partial Y 7 193, 194
cholecystectomy.
17 400, 406,
17 407,
21 442, 443
24 486
52.84...... Autotransplantation of cells N .......... ..................................
of Islets of Langerhans.
52.85...... Allotransplantation of cells N .......... ..................................
of Islets of Langerhans.
52.86...... Transplantation of cells of N .......... ..................................
Islets of Langerhans, not
otherwise specified.
54.51...... Laparoscopic lysis of Y 6 150, 151
peritoneal adhesions. 7 201
13 365
21 442, 443
24 486
54.59...... Other lysis of peritoneal Y 6 150, 151
adhesions.
7 201
13 365
21 442, 443
24 486
59.03...... Laparoscopic lysis of Y 11 303, 304, 305
perirenal or periureteral 12 344, 345
adhesions.
13 365
17 400
17 406, 407
[[Page 27543]]
21 442, 443
24 486
59.12...... Laparoscopic lysis of Y 11 308, 309
perivesical adhesions. 12 344, 345
13 365
17 400
17 406, 407
21 442, 443
24 486
65.01...... Laparoscopic oophorotomy..... Y 13 354, 355, 357, 358, 359
65.09...... Other oophorotomy............ Y 13 354, 355, 357, 358, 359
65.13...... Laparoscopic biopsy of ovary. Y 13 354, 355, 357, 358, 359
65.14...... Other laparoscopic diagnostic Y 13 354, 355, 357, 358, 359
procedures on ovaries.
65.23...... Laparoscopic marsupialization Y 13 354, 355, 357, 358, 359
of ovarian cyst.
65.24...... Laparoscopic wedge resection Y 10 292, 293
of ovary.
13 354, 355, 357, 358, 359
65.25...... Other laparoscopic local Y 13 354, 355, 357, 358, 359
excision or destruction of
ovary.
65.31...... Laparoscopic unilateral Y 13 354, 355, 357, 358, 359
oophorectomy.
65.39...... Other unilateral oophorectomy Y 13 354, 355, 357, 358, 359
65.41...... Laparoscopic unilateral Y 13 354, 355, 357, 358, 359
salpingo-oophorectomy.
65.49...... Other unilateral salpingo- Y 13 354, 355, 357, 358, 359
oophorectomy.
65.53...... Laparoscopic removal of both Y 9 269, 270
ovaries at same operative
episode.
13 354, 355,
13 357, 358, 359
65.54...... Laparoscopic removal of Y 9 269, 270
remaining ovary.
13 354, 355,
13 357, 358, 359
65.63...... Laparoscopic removal of both Y 9 269, 270
ovaries and tubes at same
operative episode.
13 354, 355,
13 357, 358, 359
65.64...... Laparoscopic removal of Y 13 354, 355, 357, 358, 359
remaining ovary and tube.
65.74...... Laparoscopic simple suture of Y 13 354, 355,
ovary.
13 357, 358,
21 359
24 442, 443, 486
65.75...... Laparoscopic reimplantation Y 13 354, 355,
of ovary.
13 357, 358,
21 359
24 442, 443, 486
65.76...... Laparoscopic salpingo- Y 13 354, 355,
oophoroplasty.
13 357, 358,
21 359
24 442, 443, 486
65.81...... Laparoscopic lysis of Y 13 354, 355,
adhesions of ovary and 13 357, 358,
fallopian tube. 21 359
24 442, 443, 486
65.89...... Other lysis of adhesions of Y 13 354, 355,
ovary and fallopian tube.
13 357, 358,
21 359
24 442, 443, 486
68.23...... Endometrial ablation......... Y 13 354, 355, 357, 358, 359
68.51...... Laparoscopically assisted Y 13 354, 355,
vaginal hysterectomy (LAVH). 13 357, 358,
14 359, 375
68.59...... Other vaginal hysterectomy... Y 13 354, 355,
13 357, 358,
14 359, 375
----------------------------------------------------------------------------------------------------------------
[[Page 27544]]
Table 6c.--Table Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
291.8......... Other specified alcoholic Y 20 434, 435, 436, 437
psychosis.
466.1......... Acute bronchiolitis......... N 4 96, 97, 98
575.1......... Other cholecystitis......... N 7 207, 208
752.5......... Undescended testicle........ N 12 352
752.6......... Hypospadias and epispadias.. N 12 352
753.2......... Obstructive defects of renal N 11 331, 332, 333
pelvis and ureter.
758.8......... Other conditions due to sex N 12 352
chromosome anomalies. 13 358, 359, 369
922.3......... Contusion of back........... N 9 280, 281,
9 282
................... 24 484, 486, 487
995.5......... Child maltreatment syndrome. N 21 454, 455
998.1......... Hemorrhage or hematoma Y 15 387 \1\, 389 \1\
complicating a procedure.
21 452, 453
998.5......... Postoperative infection..... Y 15 387 \1\, 389 \1\
18 418
V15.4......... Psychological trauma........ N 23 467
V61.1......... Marital problems............ N 23 467
----------------------------------------------------------------------------------------------------------------
\1\ Diagnosis code is classified as a ``major problem'' in these DRGs.
Table 6d.--Invalid Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
47.0.......... Appendectomy................ Y 6 164, 165, 166, 167
47.1.......... Incidental appendectomy..... Y 13 365,
21 442, 443,
24 486
54.5.......... Lysis of peritoneal Y 6 150, 151
adhesions.
7 201
13 365
21 442, 443
24 486
59.01......... Ureterolysis with freeing or Y 11 303, 304,
repositioning of ureter for
retroperitoneal fibrosis.
11 305
12 344, 345
13 365
17 400, 406,
17 407
21 442, 443
24 486
65.0.......... Oophorotomy................. Y 13 354, 355, 357, 358, 359
65.3.......... Unilateral oophorectomy..... Y 13 354, 355, 357, 358, 359
65.4.......... Unilateral salpingo- Y 13 354, 355, 357, 358, 359
oophorectomy.
65.8.......... Lysis of adhesions of ovary Y 13 354, 355,
and fallopian tube.
13 357, 358,
21 359
24 442, 443, 486
68.5.......... Vaginal hysterectomy........ Y 13 354, 355,
13 357, 358,
13 359
14 375
----------------------------------------------------------------------------------------------------------------
Table 6e.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
414.00... Coronary atherosclerosis of N 5 132, 133
unspecified type of vessel,
native or graft.
995.81... Adult physical abuse......... N 21 454, 455
997.60... Amputation stump N 8 256
complication, unspecified
complication.
997.61... Amputation stump N 8 256
complication, neuroma of
amputation stump.
997.62... Amputation stump Y 8 256
complication, infection
(chronic).
997.69... Amputation stump N 8 256
complication, not elsewhere
classified.
[[Page 27545]]
V61.20... Counseling for parent-child N 23 467
problem, unspecified.
V61.21... Counseling for victim of N 23 467
child abuse.
V67.4.... Follow-up examination, N 23 465, 466
following treatment of
healed fracture.
----------------------------------------------------------------------------------------------------------------
Table 6f.--Revised Procedure Code Titles
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
59.11...... Other lysis of perivesical Y 11 308, 309
adhesions. 12 344, 345
13 365
17 400, 406,
17 407
21 442, 443
24 486
65.51...... Other removal of both ovaries Y 9 269, 270
at same operative episode. 13 354, 355
13 357, 358, 359
65.52...... Other removal of remaining Y 9 269, 270
ovary. 13 354, 355
13 357, 358, 359
65.61...... Other removal of both ovaries Y 9 269, 270
and tubes at same operative 13 354, 355,
episode. 13 357, 358, 359
65.62...... Other removal of remaining Y 13 354, 355, 357, 358, 359
ovary and tube.
65.71...... Other simple suture of ovary. Y 13 354, 355,
13 357, 358,
13 359
21 442, 443
24 486
65.72...... Other reimplantation of ovary Y 13 354, 355,
13 357, 358,
21 359
24 442, 443, 486
65.73...... Other salpingo-oophoroplasty. Y 11 308, 309,
12 344, 345
13 365
17 400, 406,
17 407
21 442, 443
24 486
----------------------------------------------------------------------------------------------------------------
[[Page 27546]]
Table 6g.--Additions to the CC Exclusions List
Page 1 of 5 Pages
CCs that are added to the list are in Table 6G--Additions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
------------------------------------------------------------------------
*0011 00844 *00800 00844 *0085 00844 *01133 *01182
00841 00845 00841 00845 00841 00845 4831 4831
00842 00846 00842 00846 00842 00846 *01134 *01183
00843 00847 00843 00847 00843 00847 4831 4831
00844 *0061 00844 *00841 00844 *0088 *01135 *01184
00845 00841 00845 00841 00845 00841 4831 4831
00846 00842 00846 00842 00846 00842 *01136 *01185
00847 00843 00847 00843 00847 00843 4831 4831
*0020 00844 *00801 00844 *00861 00844 *01140 *01186
00841 00845 00841 00845 00841 00845 4831 4831
00842 00846 00842 00846 00842 00846 *01141 *01190
00843 00847 00843 00847 00843 00847 4831 4831
00844 *0062 00844 *00842 00844 *0090 *01142 *01191
00845 00841 00845 00841 00845 00841 4831 4831
00846 00842 00846 00842 00846 00842 *01143 *01192
00847 00843 00847 00843 00847 00843 4831 4831
*0029 00844 *00802 00844 *00862 00844 *01144 *01193
00841 00845 00841 00845 00841 00845 4831 4831
00842 00846 00842 00846 00842 00846 *01145 *01194
00843 00847 00843 00847 00843 00847 4831 4831
00844 *0069 00844 *00843 00844 *01100 *01146 *01195
00845 00841 00845 00841 00845 4831 4831 4831
00846 00842 00846 00842 00846 *01101 *01150 *01196
00847 00843 00847 00843 00847 4831 4831 4831
*0030 00844 *00803 00844 *00863 *01102 *01151 *01200
00841 00845 00841 00845 00841 4831 4831 4831
00842 00846 00842 00846 00842 *01103 *01152 *01201
00843 00847 00843 00847 00843 4831 4831 4831
00844 *0071 00844 *00844 00844 *01104 *01153 *01202
00845 00841 00845 00841 00845 4831 4831 4831
00846 00842 00846 00842 00846 *01105 *01154 *01203
00847 00843 00847 00843 00847 4831 4831 4831
*0049 00844 *00804 00844 *00864 *01106 *01155 *01204
00841 00845 00841 00845 00841 4831 4831 4831
00842 00846 00842 00846 00842 *01110 *01156 *01205
00843 00847 00843 00847 00843 4831 4831 4831
00844 *0072 00844 *00845 00844 *01111 *01160 *01206
00845 00841 00845 00841 00845 4831 4831 4831
00846 00842 00846 00842 00846 *01112 *01161 *01210
00847 00843 00847 00843 00847 4831 4831 4831
*0050 00844 *00809 00844 *00865 *01113 *01162 *01211
00841 00845 00841 00845 00841 4831 4831 4831
00842 00846 00842 00846 00842 *01114 *01163 *01212
00843 00847 00843 00847 00843 4831 4831 4831
00844 *0073 00844 *00846 00844 *01115 *01164 *01213
00845 00841 00845 00841 00845 4831 4831 4831
00846 00842 00846 00842 00846 *01116 *01165 *01214
00847 00843 00847 00843 00847 4831 4831 4831
*0051 00844 *0081 00844 *00866 *01120 *01166 *01215
00841 00845 00841 00845 00841 4831 4831 4831
00842 00846 00842 00846 00842 *01121 *01170 *01216
00843 00847 00843 00847 00843 4831 4831 4831
00844 *0078 00844 *00847 00844 *01122 *01171 *01280
00845 00841 00845 00841 00845 4831 4831 4831
00846 00842 00846 00842 00846 *01123 *01172 *01281
00847 00843 00847 00843 00847 4831 4831 4831
*0052 00844 *0082 00844 *00867 *01124 *01173 *01282
00841 00845 00841 00845 00841 4831 4831 4831
00842 00846 00842 00846 00842 *01125 *01174 *01283
00843 00847 00843 00847 00843 4831 4831 4831
00844 *0079 00844 *00849 00844 *01126 *01175 *01284
00845 00841 00845 00841 00845 4831 4831 4831
00846 00842 00846 00842 00846 *01130 *01176 *01285
00847 00843 00847 00843 00847 4831 4831 4831
*0060 00844 *0083 00844 *00869 *01131 *01180 *01286
00841 00845 00841 00845 00841 4831 4831 4831
00842 00846 00842 00846 00842 *01132 *01181 *01480
00843 00847 00843 00847 00843 4831 4831 00841
------------------------------------------------------------------------
[[Page 27547]]
Page 2 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
00842 4831 29382 29284 *29212 29383 29614 29181
00843 *11285 29383 29289 29181 29384 29634 29189
00844 00841 29384 2929 29189 7105 29644 29384
00845 00842 30300 29381 29384 *29389 29654 *30420
00846 00843 30301 29382 *2922 29181 29664 29181
00847 00844 30302 29383 29181 29189 2980 29189
*01481 00845 30390 29384 29189 29384 2983 29384
00841 00846 30391 30300 29384 *2939 2984 *30421
00842 00847 30392 30301 *29281 29181 29900 29181
00843 *11505 30400 30302 29181 29189 29910 29189
00844 4831 30401 30390 29189 29384 29980 29384
00845 *11515 30402 30391 29384 *2940 29990 *30422
00846 4831 30410 30392 *29282 29181 *30300 29181
00847 *11595 30411 30400 29181 29189 29181 29189
*01482 4831 30412 30401 29189 29384 29189 29384
00841 *1221 30420 30402 29384 *2941 29384 *30423
00842 4831 30421 30410 *29283 29181 *30301 29181
00843 *129 30411 29181 29189 29181 29189
30422
00844 00841 30440 30412 29189 29384 29189 29384
00845 00842 30441 30420 29384 *2948 29384 *30430
00846 00843 30442 30421 *29284 29181 *30302 29181
00847 00844 30450 30422 29181 29189 29181 29189
*01483 00845 30451 30440 29189 29384 29189 29384
00841 00846 30452 30441 29384 *2949 29384 *30431
00842 00847 30460 30442 *29289 29181 *30303 29181
00843 *1304 30461 30450 29181 29189 29181 29189
00844 4831 30462 30451 29189 29384 29189 29384
00845 *1363 30470 30452 29384 *30082 29384 *30432
00846 4831 30471 30460 *2929 29500 *30390 29181
00847 *2910 30472 30461 29181 29501 29181 29189
*01484 29181 30480 30462 29189 29502 29189 29384
00841 29189 30481 30470 29384 29503 29384 *30433
00842 29384 30482 30471 *2930 29504 *30391 29181
00843 *2911 30490 30472 29181 29510 29181 29189
00844 29181 30491 30480 29189 29511 29189 29384
00845 29189 30492 30481 29384 29512 29384 *30440
00846 29384 30500 30482 *2931 29513 *30392 29181
00847 *2912 30501 30490 29181 29514 29181 29189
*01485 29181 30502 30491 29189 29521 29189 29384
00841 29189 30530 30492 29384 29522 29384 *30441
00842 29384 30531 30500 *29381 29523 *30393 29181
00843 *2913 30532 30501 29181 29524 29181 29189
00844 29181 30540 30502 29189 29530 29189 29384
00845 29189 30541 30530 29384 29531 29384 *30442
00846 29384 30542 30531 *29382 29532 *30400 29181
00847 *2914 30550 30532 29181 29533 29181 29189
*01486 29181 30551 30540 29189 29534 29189 29384
00841 29189 30552 30541 29384 29540 29384 *30443
00842 29384 30560 30542 *29383 29541 *30401 29181
00843 *2915 30561 30550 29181 29542 29181 29189
00844 29181 30562 30551 29189 29543 29189 29384
00845 29189 30570 30552 29384 29544 29384 *30450
00846 29384 30571 30560 *29384 29560 *30402 29181
00847 *29181 30572 30561 2910 29561 29181 29189
*01790 2910 30590 30562 2911 29562 29189 29384
4831 2911 30591 30570 2912 29563 29384 *30451
*01791 2912 30592 30571 2913 29564 *30403 29181
4831 2913 *29189 30572 2914 29570 29181 29189
*01792 2914 2910 30590 29181 29571 29189 29384
4831 29181 2911 30591 29189 29572 29384 *30452
*01793 29189 2912 30592 2919 29573 *30410 29181
4831 2919 2913 *2919 2920 29574 29181 29189
*01794 2920 2914 29181 29211 29580 29189 29384
4831 29211 29181 29189 29212 29581 29384 *30453
*01795 29212 29189 29384 2922 29582 *30411 29181
4831 2922 2919 *2920 29281 29583 29181 29189
*01796 29281 2920 29181 29282 29584 29189 29384
4831 29282 29211 29189 29283 29590 29384 *30460
*0212 29283 29212 29384 29284 29591 *30412 29181
4831 29284 2922 *29211 29289 29592 29181 29189
*0310 29289 29281 29181 2929 29593 29189 29384
4831 2929 29282 29189 29381 29594 29384 *30461
*0391 29381 29283 29384 29382 29604 *30413 29181
------------------------------------------------------------------------
[[Page 27548]]
Page 3 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
29189 29384 *30562 29532 *48239 01180 5078 4831
29384 *30520 29181 29533 4831 01181 5080 *5062
*30462 29181 29189 29534 *4824 01182 5081 4831
29181 29189 29384 29540 4831 01183 5171 *5063
29189 29384 *30563 29541 *48281 01184 *4838 4831
29384 *30521 29181 29542 4831 01185 4831 *5064
*30463 29181 29189 29543 *48282 01186 *4841 4831
29181 29189 29384 29544 4831 01190 4831 *5069
29189 29384 *30570 29560 *48283 01191 *4843 4831
29384 *30522 29181 29561 4831 01192 4831 *5070
*30470 29181 29189 29562 *48289 01193 *4845 4831
29181 29189 29384 29563 4831 01194 4831 *5071
29189 29384 *30571 29564 *4829 01195 *4846 4831
29384 *30523 29181 29570 4831 01196 4831 *5078
*30471 29181 29189 29571 *4830 01200 *4847 4831
29181 29189 29384 29572 4831 01201 4831 *5080
29189 29384 *30572 29573 *4831 01202 *4848 4831
29384 *30530 29181 29574 01100 01203 4831 *5081
*30472 29181 29189 29580 01101 01204 *485 4831
29181 29189 29384 29581 01102 01205 4831 *5088
29189 29384 *30573 29582 01103 01206 *486 4831
29384 *30531 29181 29583 01104 01210 4831 *5089
*30473 29181 29189 29584 01105 01211 *4870 4831
29181 29189 29384 29590 01106 01212 4831 *5171
29189 29384 *30580 29591 01110 01213 *4871 4831
29384 *30532 29181 29592 01111 01214 4831 *5178
*30480 29181 29189 29593 01112 01215 *4878 4831
29181 29189 29384 29594 01113 01216 00841 *51889
29189 29384 *30581 29604 01114 0310 00842 4831
29384 *30533 29181 29614 01115 11505 00843 *5198
*30481 29181 29189 29634 01116 11515 00844 4831
29181 29189 29384 29644 01120 1304 00845 *5199
29189 29384 *30582 29654 01121 1363 00846 4831
29384 *30540 29181 29664 01122 481 00847 *53081
*30482 29181 29189 2980 01123 4820 *494
99811
29181 29189 29384 2983 01124 4821 4831 99812
29189 29384 *30583 2984 01125 4822 *4950 99813
29384 *30541 29181 29900 01126 48230 4831 *53082
*30483 29181 29189 29910 01130 48231 *4951 99811
29181 29189 29384 29980 01131 48232 4831 99812
29189 29384 *30590 29990 01132 48239 *4952 99813
29384 *30542 29181 *4560 01133 4824 4831 *53083
*30490 29181 29189 99811 01134 48281 *4953 99811
29181 29189 29384 99812 01135 48282 4831 99812
29189 29384 *30591 99813 01136 48283 *4954 99813
29384 *30543 29181 *45620 01140 48289 4831 *53089
*30491 29181 29189 99811 01141 4829 *4955 99811
29181 29189 29384 99812 01142 4830 4831 99812
29189 29384 *30592 99813 01143 4831 *4956 99813
29384 *30550 29181 *4800 01144 4838 4831 *53100
*30492 29181 29189 4831 01145 4841 *4957 99811
29181 29189 29384 *4801 01146 4843 4831 99812
29189 29384 *30593 4831 01150 4845 *4958 99813
29384 *30551 29181 *4802 01151 4846 4831 *53101
*30493 29181 29189 4831 01152 4847 *4959 99811
29181 29189 29384 *4808 01153 4848 4831 99812
29189 29384 *31532 4831 01154 485 *496
99813
29384 *30552 29500 *4809 01155 486 4831 *53120
*30500 29181 29501 4831 01156 4870 *500
99811
29181 29189 29502 *481 4950 4831 99812
01160
29189 29384 29503 4831 01161 4951 *501
99813
29384 *30553 29504 *4820 01162 4952 4831 *53121
*30501 29181 29510 4831 01163 4953 *502
99811
29181 29189 29511 *4821 01164 4954 4831 99812
29189 29384 29512 4831 01165 4955 *503
99813
29384 *30560 29513 *4822 01166 4956 4831 *53140
*30502 29181 29514 4831 01170 4957 *504
99811
29181 29189 29521 *48230 01171 4958 4831 99812
29189 29384 29522 4831 01172 4959 *505
99813
29384 *30561 29523 *48231 01173 5060 4831 *53141
*30503 29181 29524 4831 01174 5061 *5060 99811
29181 29189 29530 *48232 01175 5070 4831 99812
29189 29384 29531 4831 01176 5071 *5061 99813
------------------------------------------------------------------------
[[Page 27549]]
Page 4 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
*53160 99811 00846 00843 00844 57431 57400 57400
99811 99812 00847 00844 00845 57440 57401 57401
99812 99813 *53783 00845 00846 57441 57410 57410
99813 *53401 99811 00846 00847 57450 57411 57411
*53161 99811 99812 00847 *56202 57451 57421 57421
99811 99812 99813 *5565 99811 57460 57430 57430
99812 99813 *5550 00841 99812 57461 57431 57431
99813 *53420 00841 00842 99813 57470 57440 57440
*53200 99811 00842 00843 *56203 57471 57441 57441
99811 99812 00843 00844 99811 57490 57450 57450
99812 99813 00844 00845 99812 57491 57451 57451
99813 *53421 00845 00846 99813 5750 57470 57460
*53201 99811 00846 00847 *56212 *57461 57471 57461
99811 99812 00847 *5566 99811 57400 57480 57470
99812 99813 *5551 00841 99812 57401 57481 57471
99813 *53440 00841 00842 99813 57410 57490 57480
*53220 99811 00842 00843 *56213 57411 57491 57481
99811 99812 00843 00844 99811 57421 5750 57490
99812 99813 00844 00845 99812 57430 *57490 57491
99813 *53441 00845 00846 99813 57431 57430 5750
*53221 99811 00846 00847 *5641 57440 57431 57512
99811 99812 00847 *5568 00841 57441 57440 *57512
99812 99813 *5552 00841 00842 57450 57441 57400
99813 *53460 00841 00842 00843 57451 57450 57401
*53240 99811 00842 00843 00844 57460 57451 57410
99811 99812 00843 00844 00845 57461 57470 57411
99812 99813 00844 00845 00846 57470 57471 57421
99813 *53461 00845 00846 00847 57471 57490 57430
*53241 99811 00846 00847 *5693 57490 57491 57431
99811 99812 00847 *5569 99811 57491 *57491 57440
99812 99813 *5559 00841 99812 5750 57430 57441
99813 *53501 00841 00842 99813 *57470 57431 57450
*53260 99811 00842 00843 *56985 57430 57440 57451
99811 99812 00843 00844 99811 57431 57441 57460
99812 99813 00844 00845 99812 57440 57450 57461
99813 *53511 00845 00846 99813 57441 57451 57470
*53261 99811 00846 00847 *57430 57450 57470 57471
99811 99812 00847 *5570 57470 57451 57471 57480
99812 99813 *5560 00841 57471 57470 57490 57481
99813 *53521 00841 00842 57490 57471 57491 57490
*53300 99811 00842 00843 57491 57490 *5750 57491
99811 99812 00843 00844 *57431 57491 57460 5750
99812 99813 00844 00845 57470 *57471 57461 57512
99813 *53531 00845 00846 57471 57430 57470 *5759
*53301 99811 00846 00847 57490 57431 57471 57460
99811 99812 00847 *5571 57491 57440 57480 57461
99812 99813 *5561 00841 *57440 57441 57481 57480
99813 *53541 00841 00842 57470 57450 57490 57481
*53320 99811 00842 00843 57471 57451 57491 57512
99811 99812 00843 00844 57490 57470 57512 *5768
99812 99813 00844 00845 57491 57471 *57510 57460
99813 *53551 00845 00846 *57441 57490 57400 57461
*53321 99811 00846 00847 57470 57491 57401 57470
99811 99812 00847 *5579 57471 *57480 57410 57471
99812 99813 *5562 00841 57490 57400 57411 57480
99813 *53561 00841 00842 57491 57401 57421 57481
*53340 99811 00842 00843 *57450 57410 57430 57490
99811 99812 00843 00844 57470 57411 57431 57491
99812 99813 00844 00845 57471 57421 57440 57512
99813 *5363 00845 00846 57490 57430 57441 *5769
*53341 00841 00846 00847 57491 57431 57450 57460
99811 00842 00847 *5582 *57451 57440 57451 57461
99812 00843 *5563 00841 57470 57441 57460 57470
99813 00844 00841 00842 57471 57450 57461 57471
*53360 00845 00842 00843 57490 57451 57470 57480
99811 00846 00843 00844 57491 57470 57471 57481
99812 00847 00844 00845 *57460 57471 57480 57490
99813 *5368 00845 00846 57400 57480 57481 57491
*53361 00841 00846 00847 57401 57481 57490 57512
99811 00842 00847 *5589 57410 57490 57491 *5780
99812 00843 *5564 00841 57411 57491 5750 99811
99813 00844 00841 00842 57421 5750 57512 99812
*53400 00845 00842 00843 57430 *57481 *57511 99813
------------------------------------------------------------------------
[[Page 27550]]
Page 5 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
*5781 5996 00841 99812 9971
99811 78820 00842 99813 9972
99812 78829 00843 *99813 9973
99813 *75329 00844 9585 9974
*5789 5845 00845 9954 9975
99811 5846 00846 9980 99762
99812 5847 00847 99811 99799
99813 5849 *7758 99812 9980
*74861 585 00841 99813 9982
4831 5996 00842 *99851 9983
*75261 78820 00843 99851 9984
5970 78829 00844 99859 9986
5981 *7724 00845 *99859 9987
5982 99811 00846 99851 99883
5994 99812 00847 99859 99889
*75262 99813 *7759 *99881 9989
5970 *7750 00841 99811 *99889
5981 00841 00842 99812 99811
5982 00842 00843 99813 99812
5994 00843 00844 99851 99813
*75263 00844 00845 99859 99851
5970 00845 00846 99883 99859
5981 00846 00847 *99883 99883
5982 00847 *7775 9580 *9989
5994 *7751 00841 9581 99811
*75264 00841 00842 9582 99812
5970 00842 00843 9583 99813
5981 00843 00844 9584 99851
5982 00844 00845 9585 99859
5994 00845 00846 9587 99883
*75265 00846 00847 9954
5970 00847 *7778 99600
5981 *7752 00841 99601
5982 00841 00842 99602
5994 00842 00843 99603
*75269 00843 00844 99604
5970 00844 00845 99609
5981 00845 00846 9961
5982 00846 00847 9962
5994 00847 *7903 99630
*75320 *7753 29181 99639
5845 00841 29189 9964
5846 00842 29384 99660
5847 00843 *99791 99661
5849 00844 99811 99662
585 00845 99812 99663
5996 00846 99813 99664
78820 00847 99851 99665
78829 *7754 99859 99666
*75321 00841 99883 99667
5845 00842 *99799 99669
5846 00843 99811 99670
5847 00844 99812 99671
5849 00845 99813 99672
585 00846 99851 99673
5996 00847 99859 99674
78820 *7755 99883 99675
78829 00841 *9980 99676
*75322 00842 99811 99677
5845 00843 99812 99678
5846 00844 99813 99679
5847 00845 *99811 99690
5849 00846 9585 99691
585 00847 9954 99692
5996 *7756 9980 99693
78820 00841 99811 99694
78829 00842 99812 99695
*75323 00843 99813 99696
5845 00844 *99812 99699
5846 00845 9585 99700
5847 00846 9954 99701
5849 00847 9980 99702
585 *7757 99811 99709
------------------------------------------------------------------------
[[Page 27551]]
Table 6h.--Deletions to the CC Exclusions List
Page 1 of 1 Page
CCs that are deleted from the list are in Table 6H--Deletions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
------------------------------------------------------------------------
*2910 30502 2918 2918 2918 9981 57421
2918 30530 *30303 *30471 *30563 *53261 57430
*2911 30531 2918 2918 2918 9981 57431
2918 30532 *30390 *30472 *30570 *53300 57440
*2912 30540 2918 2918 2918 9981 57441
2918 30541 *30391 *30473 *30571 *53301 57450
*2913 30542 2918 2918 2918 9981 57451
2918 30550 *30392 *30480 *30572 *53320 5750
*2914 30551 2918 2918 2918 9981 *5780
2918 30552 *30393 *30481 *30573 *53321 9981
*2915 30560 2918 2918 2918 9981 *5781
2918 30561 *30400 *30482 *30580 *53340 9981
*2918 30562 2918 2918 2918 9981 *5789
2910 30570 *30401 *30483 *30581 *53341 9981
2911 30571 2918 2918 2918 9981 *7526
2912 30572 *30402 *30490 *30582 *53360 5970
2913 30590 2918 2918 2918 9981 5981
2914 30591 *30403 *30491 *30583 *53361 5982
2918 30592 2918 2918 2918 9981 5994
2919 *2919 *30410 *30492 *30590 *53400 *7532
2920 2918 2918 2918 2918 9981 5845
29211 *2920 *30411 *30493 *30591 *53401 5846
29212 2918 2918 2918 2918 9981 5847
2922 *29211 *30412 *30500 *30592 *53420 5849
29281 2918 2918 2918 2918 9981 585
29282 *29212 *30413 *30501 *30593 *53421 5996
29283 2918 2918 2918 2918 9981 78820
29284 *2922 *30420 *30502 *4560 *53440 78829
29289 2918 2918 2918 9981 9981 *7724
2929 *29281 *30421 *30503 *45620 *53441 9981
29381 2918 2918 2918 9981 9981 *7903
29382 *29282 *30422 *30520 *53081 *53460 2918
29383 2918 2918 2918 9981 9981 *99791
30300 *29283 *30423 *30521 *53082 *53461 9981
30301 2918 2918 2918 9981 9981 9985
30302 *29284 *30430 *30522 *53083 *53501 *99799
30390 2918 2918 2918 9981 9981 9981
30391 *29289 *30431 *30523 *53089 *53511 9985
30392 2918 2918 2918 9981 9981 *9980
30400 *2929 *30432 *30530 *53100 *53521 9981
30401 2918 2918 2918 9981 9981 *9981
30402 *2930 *30433 *30531 *53101 *53531 9585
30410 2918 2918 2918 9981 9981 9954
30411 *2931 *30440 *30532 *53120 *53541 9980
30412 2918 2918 2918 9981 9981 9981
30420 *29381 *30441 *30533 *53121 *53551 *9985
30421 2918 2918 2918 9981 9981 9985
30422 *29382 *30442 *30540 *53140 *53561 *99881
30440 2918 2918 2918 9981 9981 9981
30441 *29383 *30443 *30541 *53141 *53783 9985
30442 2918 2918 2918 9981 9981 *99889
30450 *29389 *30450 *30542 *53160 *56202 9981
30451 2918 2918 2918 9981 9981 9985
30452 *2939 *30451 *30543 *53161 *56203 *9989
30460 2918 2918 2918 9981 9981 9981
30461 *2940 *30452 *30550 *53200 *56212 9985
30462 2918 2918 2918 9981 9981
30470 *2941 30453 *30551 *53201 *56213
30471 2918 2918 2918 9981 9981
30472 *2948 *30460 *30552 *53220 *5693
30480 2918 2918 2918 9981 9981
30481 *2949 *30461 *30553 *53221 *56985
30482 2918 2918 2918 9981 9981
30490 *30300 *30462 *30560 *53240 *5751
30491 2918 2918 2918 9981 57400
30492 *30301 *30463 *30561 *53241 57401
30500 2918 2918 2918 9981 57410
30501 *30302 *30470 *30562 *53260 57411
------------------------------------------------------------------------
[[Page 27552]]
Table 7a.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
[FY95 MEDPAR Update 12/95 Grouper V13.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 32723 11.0372 3 4 8 14 23
2....................................... 6165 11.5178 3 5 8 14 23
3....................................... 1 10.0000 10 10 10 10 10
4....................................... 5866 9.1202 2 3 6 11 20
5....................................... 95896 4.4060 2 2 3 5 9
6....................................... 444 3.3581 1 1 2 4 7
7....................................... 10526 12.5752 3 5 8 14 25
8....................................... 2248 4.1348 1 1 3 5 9
9....................................... 1655 7.5287 2 3 5 9 16
10...................................... 19194 7.9610 2 3 6 10 16
11...................................... 2866 4.9215 1 2 4 6 10
12...................................... 23355 7.5868 2 3 5 9 14
13...................................... 5969 6.2406 2 4 5 7 11
14...................................... 351205 7.4178 2 3 6 9 14
15...................................... 138882 4.4367 1 2 3 5 8
16...................................... 11877 6.5858 2 3 5 8 12
17...................................... 3217 4.0258 1 2 3 5 7
18...................................... 22783 6.3682 2 3 5 8 12
19...................................... 7433 4.5271 1 2 4 6 8
20...................................... 5990 11.2129 3 5 9 15 22
21...................................... 1114 7.8905 2 3 6 10 16
22...................................... 2585 4.8584 2 2 4 6 9
23...................................... 5720 5.0336 1 2 4 6 10
24...................................... 53620 5.8059 2 3 4 7 11
25...................................... 21830 3.8592 1 2 3 5 7
26...................................... 46 4.6087 1 2 3 6 10
27...................................... 3475 6.2774 1 1 4 7 15
28...................................... 11179 7.0945 1 3 5 9 14
29...................................... 3684 4.0581 1 2 3 5 8
31...................................... 3167 5.4436 1 2 4 6 10
32...................................... 1723 3.1573 1 1 2 4 6
34...................................... 16272 6.4700 2 3 5 8 12
35...................................... 3648 4.2928 1 2 3 5 8
36...................................... 9010 1.5970 1 1 1 2 3
37...................................... 1878 4.0213 1 1 3 5 8
38...................................... 234 2.5385 1 1 2 3 5
39...................................... 3289 1.9663 1 1 1 2 4
40...................................... 2779 3.3843 1 1 2 4 7
42...................................... 7351 2.2049 1 1 1 2 5
43...................................... 97 4.0928 1 2 3 5 8
44...................................... 1614 5.7038 2 3 5 7 10
45...................................... 2412 3.8163 1 2 3 5 7
46...................................... 2952 5.4814 1 2 4 7 10
47...................................... 1333 3.7802 1 2 3 5 7
49...................................... 2139 5.6396 1 2 4 7 11
50...................................... 3347 2.1138 1 1 2 2 3
51...................................... 308 2.9870 1 1 1 3 7
52...................................... 78 3.6282 1 1 2 3 8
53...................................... 3340 3.5548 1 1 2 4 8
54...................................... 1 1.0000 1 1 1 1 1
55...................................... 1924 2.9569 1 1 2 3 6
56...................................... 704 2.7514 1 1 2 3 6
57...................................... 637 4.0973 1 1 3 5 8
59...................................... 88 3.7045 1 1 2 4 7
60...................................... 3 1.0000 1 1 1 1 1
61...................................... 217 5.2535 1 1 2 7 14
62...................................... 1 2.0000 2 2 2 2 2
63...................................... 3996 4.6652 1 2 3 5 10
64...................................... 3351 7.5067 1 2 5 9 16
65...................................... 29525 3.4147 1 2 3 4 6
66...................................... 6479 3.5658 1 2 3 4 6
67...................................... 510 4.2039 2 2 3 5 8
68...................................... 9443 4.7605 2 3 4 6 9
69...................................... 3062 3.7606 1 2 3 5 7
70...................................... 30 3.0667 1 2 3 3 5
71...................................... 90 4.1556 1 2 3 5 8
72...................................... 561 4.3529 1 2 3 5 9
73...................................... 6017 4.9493 1 2 4 6 9
75...................................... 39401 11.1088 4 6 8 14 21
76...................................... 38785 12.4555 3 6 10 15 24
[[Page 27553]]
77...................................... 2331 5.5268 1 2 4 8 12
78...................................... 28979 8.2306 4 5 7 10 13
79...................................... 207606 9.2488 3 5 7 11 17
80...................................... 8932 6.6160 2 4 5 8 12
81...................................... 9 7.2222 1 2 6 11 12
82...................................... 68573 7.8881 2 3 6 10 16
83...................................... 6976 6.3817 2 3 5 8 12
84...................................... 1430 3.7217 1 2 3 5 7
85...................................... 18398 7.3317 2 3 6 9 14
86...................................... 1372 4.5117 1 2 4 6 9
87...................................... 58612 6.7959 1 3 6 9 13
88...................................... 345365 6.0658 2 3 5 7 11
89...................................... 415072 7.0754 3 4 6 9 12
90...................................... 40306 5.1392 2 3 4 6 9
91...................................... 50 4.5800 2 2 3 6 8
92...................................... 11849 7.2524 2 4 6 9 13
93...................................... 1262 4.9374 1 3 4 6 9
94...................................... 12531 7.0527 2 3 5 9 14
95...................................... 1365 4.1341 1 2 3 5 8
96...................................... 60887 5.5101 2 3 5 7 10
97...................................... 25835 4.2614 2 2 4 5 7
98...................................... 19 4.4737 1 1 3 6 10
99...................................... 25241 3.4914 1 2 3 4 7
100..................................... 10191 2.4244 1 1 2 3 4
101..................................... 19810 5.1725 1 2 4 7 10
102..................................... 4399 3.1298 1 1 2 4 6
103..................................... 445 39.3528 10 15 29 53 80
104..................................... 22854 14.5510 6 8 12 18 26
105..................................... 19821 10.9286 5 7 9 13 19
106..................................... 96166 11.7202 6 8 10 14 19
107..................................... 61255 8.8314 5 6 7 10 14
108..................................... 6560 12.5834 4 7 10 15 23
110..................................... 59173 10.7795 3 6 9 13 20
111..................................... 5800 6.6512 3 5 6 8 10
112..................................... 191511 4.6987 1 2 4 6 9
113..................................... 45003 14.3320 4 6 10 17 28
114..................................... 8788 9.4467 2 4 7 12 18
115..................................... 10395 11.3715 4 6 9 14 20
116..................................... 81298 5.4177 1 2 4 7 11
117..................................... 4482 4.1142 1 1 2 5 8
118..................................... 6687 3.1952 1 1 2 4 7
119..................................... 1705 5.4985 1 1 3 7 13
120..................................... 40465 9.1860 1 2 6 12 21
121..................................... 158928 7.4120 2 4 6 9 13
122..................................... 87089 5.0036 1 3 5 6 9
123..................................... 46281 4.6510 1 1 2 6 11
124..................................... 138564 4.8885 1 2 4 6 9
125..................................... 59232 3.0694 1 1 2 4 6
126..................................... 4619 13.9985 4 7 11 17 29
127..................................... 670461 6.2113 2 3 5 8 12
128..................................... 19612 6.7259 3 4 6 8 11
129..................................... 4584 3.4271 1 1 1 4 9
130..................................... 91826 6.6818 2 4 6 8 12
131..................................... 25592 5.1808 1 3 5 7 8
132..................................... 127274 3.5716 1 2 3 4 6
133..................................... 5813 2.9696 1 1 2 4 5
134..................................... 28493 3.9142 1 2 3 5 7
135..................................... 7141 4.9779 1 2 4 6 9
136..................................... 1014 3.2209 1 2 3 4 6
138..................................... 195932 4.5466 1 2 3 6 8
139..................................... 67345 2.9337 1 1 2 4 5
140..................................... 175930 3.4831 1 2 3 4 6
141..................................... 76111 4.4923 1 2 3 5 8
142..................................... 35701 3.1999 1 2 2 4 6
143..................................... 132318 2.6077 1 1 2 3 5
144..................................... 66761 5.6816 1 2 4 7 11
145..................................... 6735 3.2413 1 1 2 4 6
146..................................... 8626 11.2570 6 7 9 13 18
147..................................... 1624 7.3651 4 6 7 9 11
148..................................... 140141 13.4097 6 8 11 16 24
[[Page 27554]]
149..................................... 15769 7.7194 4 6 7 9 11
150..................................... 22516 11.6884 4 7 10 14 21
151..................................... 4518 6.4748 2 4 6 8 11
152..................................... 4469 9.0257 4 6 8 10 15
153..................................... 1710 6.1655 3 4 6 8 9
154..................................... 35661 14.9524 5 8 12 18 28
155..................................... 4557 5.8824 2 3 5 8 10
156..................................... 4 15.7500 4 4 10 22 27
157..................................... 11419 5.7824 1 2 4 7 11
158..................................... 5082 2.9124 1 1 2 4 6
159..................................... 17132 5.3155 1 2 4 7 10
160..................................... 9971 2.9553 1 1 2 4 5
161..................................... 14786 4.3655 1 2 3 5 9
162..................................... 7990 2.1914 1 1 2 3 4
163..................................... 5 2.2000 1 1 1 3 5
164..................................... 4995 9.2993 4 6 8 11 16
165..................................... 1674 5.7575 3 4 5 7 9
166..................................... 3283 5.7286 2 3 4 7 10
167..................................... 2284 3.2439 1 2 3 4 6
168..................................... 1739 4.8562 1 2 3 6 10
169..................................... 1025 2.5473 1 1 2 3 5
170..................................... 12463 12.4436 2 5 9 15 25
171..................................... 1157 5.4105 1 2 4 7 11
172..................................... 30820 8.1481 2 3 6 10 16
173..................................... 2188 4.2870 1 2 3 5 9
174..................................... 231782 5.5456 2 3 4 7 10
175..................................... 23071 3.5073 1 2 3 4 6
176..................................... 16011 6.1346 2 3 5 7 11
177..................................... 11991 4.9873 2 3 4 6 9
178..................................... 4174 3.6195 1 2 3 5 7
179..................................... 11198 7.1657 2 4 6 9 14
180..................................... 79145 6.0471 2 3 5 7 11
181..................................... 22152 3.9606 1 2 3 5 7
182..................................... 226099 4.9591 2 2 4 6 9
183..................................... 72147 3.4552 1 2 3 4 6
184..................................... 67 3.7463 1 2 2 4 6
185..................................... 3804 5.1966 1 2 4 6 10
186..................................... 1 2.0000 2 2 2 2 2
187..................................... 832 4.2524 1 2 3 6 8
188..................................... 61112 6.1262 2 3 5 8 12
189..................................... 7787 3.6773 1 1 3 5 7
190..................................... 62 4.8548 1 3 4 6 10
191..................................... 10459 16.1606 5 8 12 20 32
192..................................... 880 7.9625 2 4 7 9 14
193..................................... 8477 13.8662 5 8 11 17 25
194..................................... 805 8.4348 3 5 7 10 15
195..................................... 9196 10.4533 4 6 9 12 18
196..................................... 796 6.7651 3 4 6 8 11
197..................................... 28016 9.1380 4 5 7 11 16
198..................................... 7906 4.9586 2 3 4 6 8
199..................................... 2208 11.1005 3 5 9 14 22
200..................................... 1525 11.8413 2 4 8 14 25
201..................................... 1466 16.5750 4 7 13 21 34
202..................................... 25094 7.6794 2 3 6 9 15
203..................................... 28743 7.6566 2 3 6 10 15
204..................................... 49035 6.6942 2 3 5 8 13
205..................................... 21512 7.2152 2 3 5 9 14
206..................................... 1692 4.7305 1 2 4 6 10
207..................................... 35330 5.7193 2 3 4 7 11
208..................................... 10251 3.4474 1 2 3 4 6
209..................................... 328015 6.6569 3 4 6 7 10
210..................................... 131592 8.5557 4 5 7 10 14
211..................................... 25325 6.2610 3 4 6 7 10
212..................................... 9 5.0000 2 3 4 5 8
213..................................... 6788 9.6117 3 4 7 12 19
214..................................... 51282 6.4551 2 3 5 8 12
215..................................... 41115 3.6816 1 2 3 5 7
216..................................... 6435 11.0449 2 5 8 14 22
217..................................... 19341 15.2991 3 6 10 18 31
218..................................... 21844 6.2064 2 3 5 7 11
[[Page 27555]]
219..................................... 17973 3.7492 1 2 3 5 6
220..................................... 2 5.5000 5 5 6 6 6
221..................................... 4962 8.1475 2 4 6 10 16
222..................................... 3560 4.0573 1 2 3 5 8
223..................................... 18306 2.8650 1 1 2 3 5
224..................................... 7946 2.2699 1 1 2 3 4
225..................................... 6199 5.0045 1 2 3 6 11
226..................................... 5349 6.7080 1 2 4 8 14
227..................................... 4604 2.9622 1 1 2 4 6
228..................................... 3014 3.5551 1 1 2 4 7
229..................................... 1345 2.4007 1 1 2 3 5
230..................................... 2455 5.1548 1 2 3 6 11
231..................................... 10331 5.0624 1 2 3 6 11
232..................................... 576 4.5017 1 1 2 5 10
233..................................... 4538 8.9595 2 4 7 11 18
234..................................... 2220 4.1730 1 2 3 5 8
235..................................... 5543 6.7231 1 3 4 7 13
236..................................... 37803 6.2862 2 3 5 7 12
237..................................... 1510 4.4139 1 2 3 5 8
238..................................... 7538 10.0649 3 5 7 12 19
239..................................... 59581 7.6027 2 4 6 9 14
240..................................... 12047 7.4987 2 3 5 9 15
241..................................... 3019 4.6277 1 2 4 6 9
242..................................... 2528 7.6606 2 4 6 9 15
243..................................... 79979 5.6107 2 3 4 7 10
244..................................... 11456 5.8092 2 3 4 7 11
245..................................... 4259 4.2158 1 2 3 5 8
246..................................... 1312 4.5899 1 2 4 6 9
247..................................... 10591 3.9716 1 2 3 5 8
248..................................... 6767 5.2815 1 2 4 6 10
249..................................... 10077 4.2995 1 2 3 5 9
250..................................... 3178 4.9091 1 2 3 6 9
251..................................... 2090 3.2933 1 1 3 4 6
252..................................... 1 1.0000 1 1 1 1 1
253..................................... 17469 5.8164 2 3 4 7 11
254..................................... 9208 3.8588 1 2 3 5 7
255..................................... 1 2.0000 2 2 2 2 2
256..................................... 4600 5.7178 1 2 4 7 11
257..................................... 23640 3.4239 1 2 3 4 6
258..................................... 18784 2.4905 1 2 2 3 4
259..................................... 4010 3.5077 1 1 2 3 7
260..................................... 4868 1.8683 1 1 1 2 3
261..................................... 2334 2.3500 1 1 2 3 4
262..................................... 712 3.9284 1 1 2 5 8
263..................................... 29088 13.8669 4 6 10 16 28
264..................................... 3559 8.3442 2 4 6 10 17
265..................................... 4274 7.6467 1 2 5 9 16
266..................................... 2712 3.6855 1 1 3 5 7
267..................................... 222 4.0811 1 1 3 5 9
268..................................... 891 4.0000 1 1 2 4 9
269..................................... 10173 9.1218 2 3 7 12 18
270..................................... 3456 3.3958 1 1 2 4 8
271..................................... 21515 8.4984 3 4 7 10 15
272..................................... 5863 7.4481 2 3 6 9 14
273..................................... 1426 5.5035 2 2 4 7 11
274..................................... 2526 7.7458 2 3 5 9 15
275..................................... 250 3.5040 1 1 2 4 8
276..................................... 889 5.0472 1 2 4 6 9
277..................................... 79054 6.7240 3 4 5 8 12
278..................................... 26008 5.1420 2 3 4 6 9
279..................................... 5 4.8000 2 2 3 4 12
280..................................... 13098 5.1142 1 2 4 6 9
281..................................... 5890 3.6448 1 2 3 4 7
283..................................... 5233 5.4888 2 2 4 7 10
284..................................... 1755 3.8632 1 2 3 5 7
285..................................... 4886 13.5014 3 6 10 16 26
286..................................... 1918 8.7195 3 4 6 9 16
287..................................... 6284 13.3908 3 6 9 16 26
288..................................... 957 7.0449 2 4 5 7 11
289..................................... 4992 3.9732 1 2 2 4 8
[[Page 27556]]
290..................................... 8514 2.8404 1 1 2 3 5
291..................................... 86 1.7558 1 1 1 2 3
292..................................... 5046 12.6958 2 5 9 16 25
293..................................... 294 6.4456 1 3 5 8 14
294..................................... 86024 5.6681 2 3 4 7 10
295..................................... 3712 4.2826 1 2 3 5 8
296..................................... 218940 6.3561 2 3 5 8 12
297..................................... 31455 4.2781 1 2 3 5 8
298..................................... 95 3.0211 1 1 2 4 5
299..................................... 868 5.3652 1 2 4 7 10
300..................................... 14115 7.3032 2 3 6 9 14
301..................................... 2146 4.3877 1 2 3 6 9
302..................................... 7567 12.3190 6 7 9 14 21
303..................................... 18462 10.1938 4 6 8 12 18
304..................................... 12867 10.2970 3 5 7 13 21
305..................................... 2526 4.9097 1 3 4 6 9
306..................................... 11305 6.2204 2 2 4 8 13
307..................................... 2596 2.9819 1 2 2 3 5
308..................................... 9137 7.0113 1 2 5 9 15
309..................................... 3371 3.0009 1 1 2 4 6
310..................................... 28549 4.6077 1 2 3 6 9
311..................................... 9697 2.1734 1 1 2 3 4
312..................................... 1995 4.7895 1 2 3 6 10
313..................................... 745 2.2644 1 1 2 3 5
314..................................... 1 5.0000 5 5 5 5 5
315..................................... 27722 9.2695 1 2 6 12 20
316..................................... 69941 7.4958 2 3 6 9 15
317..................................... 779 2.8434 1 1 2 3 6
318..................................... 5981 7.1195 2 3 5 9 14
319..................................... 506 3.2174 1 1 2 4 7
320..................................... 169078 6.4297 2 3 5 8 11
321..................................... 25512 4.7020 2 3 4 6 8
322..................................... 81 4.3580 2 2 4 6 8
323..................................... 17690 3.5573 1 2 3 4 7
324..................................... 8755 2.0870 1 1 2 3 4
325..................................... 7381 4.5898 1 2 3 5 9
326..................................... 2186 3.4492 1 1 2 4 6
327..................................... 8 3.1250 1 2 2 2 4
328..................................... 817 4.2742 1 2 3 5 9
329..................................... 109 2.7523 1 1 2 3 5
330..................................... 1 1.0000 1 1 1 1 1
331..................................... 38181 6.1753 2 3 5 8 12
332..................................... 4687 3.8835 1 2 3 5 8
333..................................... 357 5.8319 1 3 4 7 13
334..................................... 19011 6.0503 3 4 5 7 9
335..................................... 9821 4.5786 2 3 4 6 7
336..................................... 60748 4.1251 1 2 3 5 8
337..................................... 38538 2.6717 1 2 2 3 4
338..................................... 4813 5.2703 1 2 3 6 11
339..................................... 2302 4.9392 1 2 3 6 10
340..................................... 2 3.0000 1 1 5 5 5
341..................................... 6427 3.2367 1 1 2 4 6
342..................................... 224 4.0089 1 1 2 5 8
344..................................... 3820 3.4652 1 1 2 4 7
345..................................... 1355 3.9734 1 2 3 4 9
346..................................... 5343 6.7477 1 3 5 8 14
347..................................... 418 3.3349 1 1 2 4 7
348..................................... 3021 4.8875 1 2 4 6 9
349..................................... 684 2.9956 1 1 2 4 6
350..................................... 6884 4.7451 2 3 4 6 8
352..................................... 576 3.9392 1 2 3 5 8
353..................................... 2621 8.3564 3 5 6 10 15
354..................................... 9693 6.3330 3 4 5 7 11
355..................................... 5607 3.8639 2 3 4 4 6
356..................................... 28647 3.0247 1 2 3 4 5
357..................................... 6526 9.8462 4 5 8 12 18
358..................................... 26797 4.7425 2 3 4 5 8
359..................................... 27392 3.2715 2 3 3 4 5
360..................................... 16717 3.5393 1 2 3 4 6
361..................................... 618 3.4644 1 1 2 4 7
[[Page 27557]]
363..................................... 4355 3.4953 1 2 2 3 6
364..................................... 1778 3.6310 1 1 2 5 8
365..................................... 2396 8.1123 2 3 5 10 18
366..................................... 4470 7.6707 2 3 5 10 16
367..................................... 544 3.3107 1 1 2 4 7
368..................................... 2285 6.9190 2 3 5 9 13
369..................................... 2409 3.7410 1 1 3 5 7
370..................................... 1083 5.5568 3 3 4 5 9
371..................................... 950 3.5874 2 3 3 4 5
372..................................... 809 3.3498 1 2 2 3 6
373..................................... 3637 1.9249 1 1 2 2 3
374..................................... 116 2.3621 1 2 2 2 3
375..................................... 5 2.2000 1 1 2 3 4
376..................................... 151 3.4834 1 1 2 4 8
377..................................... 26 3.2308 1 1 1 3 8
378..................................... 163 2.9755 1 2 3 3 5
379..................................... 309 2.9256 1 1 2 3 5
380..................................... 71 2.3239 1 1 2 3 4
381..................................... 194 2.2835 1 1 1 2 5
382..................................... 47 1.6596 1 1 1 1 3
383..................................... 1455 4.0460 1 2 3 5 8
384..................................... 123 3.3496 1 1 1 3 7
385..................................... 3 17.0000 1 1 1 49 49
389..................................... 24 10.6667 3 4 8 10 18
390..................................... 10 5.0000 1 2 3 6 9
392..................................... 2467 11.6700 4 6 8 15 24
394..................................... 1642 7.8831 1 2 5 9 16
395..................................... 65671 5.3672 1 2 4 7 10
396..................................... 18 3.9444 1 1 3 7 8
397..................................... 15421 6.0683 2 3 4 7 12
398..................................... 16602 6.5798 2 3 5 8 12
399..................................... 1424 4.4347 1 2 4 6 8
400..................................... 7470 10.3424 2 4 7 13 23
401..................................... 6368 12.3990 2 5 9 16 25
402..................................... 1542 4.6984 1 1 3 6 10
403..................................... 34812 9.2838 2 4 7 12 19
404..................................... 3946 5.0867 1 2 4 7 10
406..................................... 3264 11.1468 3 5 8 14 23
407..................................... 723 4.9267 1 2 4 6 9
408..................................... 2949 8.2035 1 2 5 10 18
409..................................... 5649 6.6516 2 3 4 6 14
410..................................... 85873 3.3544 1 2 3 4 5
411..................................... 50 2.5600 1 1 2 3 7
412..................................... 35 3.0857 1 1 2 4 8
413..................................... 8421 8.2956 2 3 6 10 17
414..................................... 797 5.2070 1 2 4 7 11
415..................................... 38804 15.6974 4 7 12 19 31
416..................................... 192133 8.2122 2 4 7 10 15
417..................................... 45 4.6222 1 2 4 7 10
418..................................... 18663 6.7433 2 3 5 8 13
419..................................... 15677 5.6580 2 3 4 7 10
420..................................... 2871 4.3006 2 2 4 5 8
421..................................... 11386 4.6473 2 2 4 6 8
422..................................... 89 3.6854 1 2 3 4 7
423..................................... 9118 8.6534 2 4 6 10 18
424..................................... 1990 17.7397 3 6 12 20 34
425..................................... 15247 4.8955 1 2 3 6 10
426..................................... 4721 5.4938 1 2 4 7 11
427..................................... 1773 5.2775 1 2 4 7 11
428..................................... 904 8.4303 1 3 5 10 18
429..................................... 38861 8.9079 2 3 6 10 17
430..................................... 53430 9.7495 2 4 7 12 19
431..................................... 190 7.4632 1 3 5 9 14
432..................................... 430 6.3395 1 2 4 6 11
433..................................... 7843 3.4051 1 1 2 4 7
434..................................... 20810 5.8148 2 3 4 7 11
435..................................... 15477 4.8166 1 3 4 6 8
436..................................... 2915 14.5413 4 8 14 21 28
437..................................... 14205 10.8943 4 6 10 14 20
439..................................... 867 8.9262 2 3 6 11 18
[[Page 27558]]
440..................................... 4751 9.7838 2 3 6 12 21
441..................................... 611 4.4386 1 1 2 4 7
442..................................... 13818 8.7372 1 3 6 11 18
443..................................... 3299 3.5335 1 1 2 5 7
444..................................... 3319 5.3203 1 3 4 6 10
445..................................... 1321 3.7858 1 2 3 5 7
446..................................... 1 1.0000 1 1 1 1 1
447..................................... 3816 2.7953 1 1 2 3 5
448..................................... 84 1.0000 1 1 1 1 1
449..................................... 28775 4.4101 1 2 3 5 9
450..................................... 6807 2.3364 1 1 2 3 5
451..................................... 7 6.1429 2 3 4 5 7
452..................................... 19382 5.4066 1 2 4 6 11
453..................................... 3636 3.1876 1 1 2 4 6
454..................................... 5132 5.1046 1 2 3 6 10
455..................................... 1092 2.8333 1 1 2 3 5
456..................................... 194 8.3711 1 1 4 9 21
457..................................... 127 4.7953 1 1 2 5 10
458..................................... 1550 16.9387 4 7 13 22 35
459..................................... 533 10.3471 2 4 7 13 22
460..................................... 2303 6.6309 1 3 5 8 13
461..................................... 3040 4.8862 1 1 2 5 12
462..................................... 9360 13.7955 5 6 12 18 26
463..................................... 11987 5.1410 1 2 4 6 10
464..................................... 3079 3.7347 1 2 3 5 7
465..................................... 197 3.9086 1 1 2 4 7
466..................................... 1838 4.6366 1 1 2 4 10
467..................................... 1722 4.1057 1 1 2 4 8
468..................................... 58649 15.1829 3 7 12 19 30
471..................................... 9111 8.0289 4 5 6 9 13
472..................................... 150 30.6667 2 9 28 41 62
473..................................... 8217 14.3113 2 4 8 21 35
475..................................... 89514 12.1394 2 5 10 16 24
476..................................... 6875 13.7876 3 7 11 17 25
477..................................... 28128 8.8453 1 3 6 11 18
478..................................... 117755 8.2916 1 3 6 10 17
479..................................... 17758 4.5591 1 2 4 6 9
480..................................... 359 29.7159 10 13 22 37 61
481..................................... 119 35.0000 21 23 30 39 59
482..................................... 6754 14.9011 5 8 11 17 28
483..................................... 36200 45.7958 15 23 37 56 84
484..................................... 327 15.3364 2 6 11 21 32
485..................................... 3165 11.5893 4 6 9 13 21
486..................................... 2045 13.3482 1 6 11 18 28
487..................................... 3765 8.8770 1 3 7 11 17
488..................................... 1593 17.5267 5 8 13 22 35
489..................................... 17612 10.3989 2 4 7 13 22
490..................................... 4999 6.5719 1 2 4 8 14
491..................................... 9441 4.2777 2 3 3 5 7
492..................................... 2029 17.3834 3 5 10 28 37
493..................................... 52260 5.8809 1 2 5 8 11
494..................................... 27127 2.4245 1 1 2 3 5
495..................................... 107 23.7944 10 13 18 29 41
================
10571233
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7b.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
[FY95 MEDPAR Update 12/95 Grouper V14.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 32723 11.0372 3 4 8 14 23
2....................................... 6165 11.5178 3 5 8 14 23
3....................................... 1 10.0000 10 10 10 10 10
4....................................... 5866 9.1202 2 3 6 11 20
5....................................... 95896 4.4060 2 2 3 5 9
6....................................... 444 3.3581 1 1 2 4 7
7....................................... 10526 12.5752 3 5 8 14 25
[[Page 27559]]
8....................................... 2248 4.1348 1 1 3 5 9
9....................................... 1655 7.5287 2 3 5 9 16
10...................................... 19194 7.9610 2 3 6 10 16
11...................................... 2866 4.9215 1 2 4 6 10
12...................................... 23355 7.5868 2 3 5 9 14
13...................................... 5969 6.2406 2 4 5 7 11
14...................................... 351205 7.4178 2 3 6 9 14
15...................................... 138882 4.4367 1 2 3 5 8
16...................................... 11877 6.5858 2 3 5 8 12
17...................................... 3217 4.0258 1 2 3 5 7
18...................................... 22783 6.3682 2 3 5 8 12
19...................................... 7433 4.5271 1 2 4 6 8
20...................................... 5990 11.2129 3 5 9 15 22
21...................................... 1114 7.8905 2 3 6 10 16
22...................................... 2585 4.8584 2 2 4 6 9
23...................................... 5720 5.0336 1 2 4 6 10
24...................................... 53620 5.8059 2 3 4 7 11
25...................................... 21830 3.8592 1 2 3 5 7
26...................................... 46 4.6087 1 2 3 6 10
27...................................... 3475 6.2774 1 1 4 7 15
28...................................... 11179 7.0945 1 3 5 9 14
29...................................... 3684 4.0581 1 2 3 5 8
31...................................... 3167 5.4436 1 2 4 6 10
32...................................... 1723 3.1573 1 1 2 4 6
34...................................... 16272 6.4700 2 3 5 8 12
35...................................... 3648 4.2928 1 2 3 5 8
36...................................... 9010 1.5970 1 1 1 2 3
37...................................... 1878 4.0213 1 1 3 5 8
38...................................... 234 2.5385 1 1 2 3 5
39...................................... 3289 1.9663 1 1 1 2 4
40...................................... 2779 3.3843 1 1 2 4 7
42...................................... 7351 2.2049 1 1 1 2 5
43...................................... 97 4.0928 1 2 3 5 8
44...................................... 1614 5.7038 2 3 5 7 10
45...................................... 2412 3.8163 1 2 3 5 7
46...................................... 2952 5.4814 1 2 4 7 10
47...................................... 1333 3.7802 1 2 3 5 7
49...................................... 2139 5.6396 1 2 4 7 11
50...................................... 3347 2.1138 1 1 2 2 3
51...................................... 308 2.9870 1 1 1 3 7
52...................................... 78 3.6282 1 1 2 3 8
53...................................... 3340 3.5548 1 1 2 4 8
54...................................... 1 1.0000 1 1 1 1 1
55...................................... 1924 2.9569 1 1 2 3 6
56...................................... 704 2.7514 1 1 2 3 6
57...................................... 637 4.0973 1 1 3 5 8
59...................................... 88 3.7045 1 1 2 4 7
60...................................... 3 1.0000 1 1 1 1 1
61...................................... 217 5.2535 1 1 2 7 14
62...................................... 1 2.0000 2 2 2 2 2
63...................................... 3996 4.6652 1 2 3 5 10
64...................................... 3351 7.5067 1 2 5 9 16
65...................................... 29525 3.4147 1 2 3 4 6
66...................................... 6479 3.5658 1 2 3 4 6
67...................................... 510 4.2039 2 2 3 5 8
68...................................... 9443 4.7605 2 3 4 6 9
69...................................... 3062 3.7606 1 2 3 5 7
70...................................... 30 3.0667 1 2 3 3 5
71...................................... 90 4.1556 1 2 3 5 8
72...................................... 561 4.3529 1 2 3 5 9
73...................................... 6017 4.9493 1 2 4 6 9
75...................................... 39401 11.1088 4 6 8 14 21
76...................................... 38785 12.4555 3 6 10 15 24
77...................................... 2331 5.5268 1 2 4 8 12
78...................................... 28979 8.2306 4 5 7 10 13
79...................................... 207606 9.2488 3 5 7 11 17
80...................................... 8932 6.6160 2 4 5 8 12
81...................................... 9 7.2222 1 2 6 11 12
82...................................... 68573 7.8881 2 3 6 10 16
83...................................... 6976 6.3817 2 3 5 8 12
[[Page 27560]]
84...................................... 1430 3.7217 1 2 3 5 7
85...................................... 18398 7.3317 2 3 6 9 14
86...................................... 1372 4.5117 1 2 4 6 9
87...................................... 58612 6.7959 1 3 6 9 13
88...................................... 345365 6.0658 2 3 5 7 11
89...................................... 415072 7.0754 3 4 6 9 12
90...................................... 40306 5.1392 2 3 4 6 9
91...................................... 50 4.5800 2 2 3 6 8
92...................................... 11849 7.2524 2 4 6 9 13
93...................................... 1262 4.9374 1 3 4 6 9
94...................................... 12531 7.0527 2 3 5 9 14
95...................................... 1365 4.1341 1 2 3 5 8
96...................................... 60887 5.5101 2 3 5 7 10
97...................................... 25835 4.2614 2 2 4 5 7
98...................................... 19 4.4737 1 1 3 6 10
99...................................... 25241 3.4914 1 2 3 4 7
100..................................... 10191 2.4244 1 1 2 3 4
101..................................... 19810 5.1725 1 2 4 7 10
102..................................... 4399 3.1298 1 1 2 4 6
103..................................... 445 39.3528 10 15 29 53 80
104..................................... 22854 14.5510 6 8 12 18 26
105..................................... 19821 10.9286 5 7 9 13 19
106..................................... 96166 11.7202 6 8 10 14 19
107..................................... 61255 8.8314 5 6 7 10 14
108..................................... 6560 12.5834 4 7 10 15 23
110..................................... 59173 10.7795 3 6 9 13 20
111..................................... 5800 6.6512 3 5 6 8 10
112..................................... 191511 4.6987 1 2 4 6 9
113..................................... 45003 14.3320 4 6 10 17 28
114..................................... 8788 9.4467 2 4 7 12 18
115..................................... 10395 11.3715 4 6 9 14 20
116..................................... 81298 5.4177 1 2 4 7 11
117..................................... 4482 4.1142 1 1 2 5 8
118..................................... 6687 3.1952 1 1 2 4 7
119..................................... 1705 5.4985 1 1 3 7 13
120..................................... 40465 9.1860 1 2 6 12 21
121..................................... 158928 7.4120 2 4 6 9 13
122..................................... 87089 5.0036 1 3 5 6 9
123..................................... 46281 4.6510 1 1 2 6 11
124..................................... 138564 4.8885 1 2 4 6 9
125..................................... 59232 3.0694 1 1 2 4 6
126..................................... 4619 13.9985 4 7 11 17 29
127..................................... 670461 6.2113 2 3 5 8 12
128..................................... 19612 6.7259 3 4 6 8 11
129..................................... 4584 3.4271 1 1 1 4 9
130..................................... 91826 6.6818 2 4 6 8 12
131..................................... 25592 5.1808 1 3 5 7 8
132..................................... 127274 3.5716 1 2 3 4 6
133..................................... 5813 2.9696 1 1 2 4 5
134..................................... 28493 3.9142 1 2 3 5 7
135..................................... 7141 4.9779 1 2 4 6 9
136..................................... 1014 3.2209 1 2 3 4 6
138..................................... 195932 4.5466 1 2 3 6 8
139..................................... 67345 2.9337 1 1 2 4 5
140..................................... 175930 3.4831 1 2 3 4 6
141..................................... 76111 4.4923 1 2 3 5 8
142..................................... 35701 3.1999 1 2 2 4 6
143..................................... 132318 2.6077 1 1 2 3 5
144..................................... 66761 5.6816 1 2 4 7 11
145..................................... 6735 3.2413 1 1 2 4 6
146..................................... 8626 11.2570 6 7 9 13 18
147..................................... 1624 7.3651 4 6 7 9 11
148..................................... 140141 13.4097 6 8 11 16 24
149..................................... 15769 7.7194 4 6 7 9 11
150..................................... 22516 11.6884 4 7 10 14 21
151..................................... 4518 6.4748 2 4 6 8 11
152..................................... 4469 9.0257 4 6 8 10 15
153..................................... 1710 6.1655 3 4 6 8 9
154..................................... 35661 14.9524 5 8 12 18 28
155..................................... 4557 5.8824 2 3 5 8 10
[[Page 27561]]
156..................................... 4 15.7500 4 4 10 22 27
157..................................... 11419 5.7824 1 2 4 7 11
158..................................... 5082 2.9124 1 1 2 4 6
159..................................... 17132 5.3155 1 2 4 7 10
160..................................... 9971 2.9553 1 1 2 4 5
161..................................... 14786 4.3655 1 2 3 5 9
162..................................... 7990 2.1914 1 1 2 3 4
163..................................... 5 2.2000 1 1 1 3 5
164..................................... 4995 9.2993 4 6 8 11 16
165..................................... 1674 5.7575 3 4 5 7 9
166..................................... 3283 5.7286 2 3 4 7 10
167..................................... 2284 3.2439 1 2 3 4 6
168..................................... 1739 4.8562 1 2 3 6 10
169..................................... 1025 2.5473 1 1 2 3 5
170..................................... 12463 12.4436 2 5 9 15 25
171..................................... 1157 5.4105 1 2 4 7 11
172..................................... 30820 8.1481 2 3 6 10 16
173..................................... 2188 4.2870 1 2 3 5 9
174..................................... 231782 5.5456 2 3 4 7 10
175..................................... 23071 3.5073 1 2 3 4 6
176..................................... 16011 6.1346 2 3 5 7 11
177..................................... 11991 4.9873 2 3 4 6 9
178..................................... 4174 3.6195 1 2 3 5 7
179..................................... 11198 7.1657 2 4 6 9 14
180..................................... 79145 6.0471 2 3 5 7 11
181..................................... 22152 3.9606 1 2 3 5 7
182..................................... 226099 4.9591 2 2 4 6 9
183..................................... 72147 3.4552 1 2 3 4 6
184..................................... 67 3.7463 1 2 2 4 6
185..................................... 3804 5.1966 1 2 4 6 10
186..................................... 1 2.0000 2 2 2 2 2
187..................................... 832 4.2524 1 2 3 6 8
188..................................... 61112 6.1262 2 3 5 8 12
189..................................... 7787 3.6773 1 1 3 5 7
190..................................... 62 4.8548 1 3 4 6 10
191..................................... 10459 16.1606 5 8 12 20 32
192..................................... 880 7.9625 2 4 7 9 14
193..................................... 8477 13.8662 5 8 11 17 25
194..................................... 805 8.4348 3 5 7 10 15
195..................................... 9196 10.4533 4 6 9 12 18
196..................................... 796 6.7651 3 4 6 8 11
197..................................... 28016 9.1380 4 5 7 11 16
198..................................... 7906 4.9586 2 3 4 6 8
199..................................... 2208 11.1005 3 5 9 14 22
200..................................... 1525 11.8413 2 4 8 14 25
201..................................... 1466 16.5750 4 7 13 21 34
202..................................... 25094 7.6794 2 3 6 9 15
203..................................... 28743 7.6566 2 3 6 10 15
204..................................... 49035 6.6942 2 3 5 8 13
205..................................... 21512 7.2152 2 3 5 9 14
206..................................... 1692 4.7305 1 2 4 6 10
207..................................... 35330 5.7193 2 3 4 7 11
208..................................... 10251 3.4474 1 2 3 4 6
209..................................... 328015 6.6569 3 4 6 7 10
210..................................... 131592 8.5557 4 5 7 10 14
211..................................... 25325 6.2610 3 4 6 7 10
212..................................... 9 5.0000 2 3 4 5 8
213..................................... 6789 9.6170 3 4 7 12 19
214..................................... 51282 6.4551 2 3 5 8 12
215..................................... 41115 3.6816 1 2 3 5 7
216..................................... 6435 11.0449 2 5 8 14 22
217..................................... 19341 15.2991 3 6 10 18 31
218..................................... 21844 6.2064 2 3 5 7 11
219..................................... 17973 3.7492 1 2 3 5 6
220..................................... 2 5.5000 5 5 6 6 6
221..................................... 4962 8.1475 2 4 6 10 16
222..................................... 3560 4.0573 1 2 3 5 8
223..................................... 18306 2.8650 1 1 2 3 5
224..................................... 7946 2.2699 1 1 2 3 4
225..................................... 6199 5.0045 1 2 3 6 11
[[Page 27562]]
226..................................... 5349 6.7080 1 2 4 8 14
227..................................... 4604 2.9622 1 1 2 4 6
228..................................... 3014 3.5551 1 1 2 4 7
229..................................... 1345 2.4007 1 1 2 3 5
230..................................... 2455 5.1548 1 2 3 6 11
231..................................... 10331 5.0624 1 2 3 6 11
232..................................... 576 4.5017 1 1 2 5 10
233..................................... 4538 8.9595 2 4 7 11 18
234..................................... 2220 4.1730 1 2 3 5 8
235..................................... 5543 6.7231 1 3 4 7 13
236..................................... 37803 6.2862 2 3 5 7 12
237..................................... 1510 4.4139 1 2 3 5 8
238..................................... 7538 10.0649 3 5 7 12 19
239..................................... 59580 7.6024 2 4 6 9 14
240..................................... 12047 7.4987 2 3 5 9 15
241..................................... 3019 4.6277 1 2 4 6 9
242..................................... 2528 7.6606 2 4 6 9 15
243..................................... 79979 5.6107 2 3 4 7 10
244..................................... 11456 5.8092 2 3 4 7 11
245..................................... 4259 4.2158 1 2 3 5 8
246..................................... 1312 4.5899 1 2 4 6 9
247..................................... 10591 3.9716 1 2 3 5 8
248..................................... 6767 5.2815 1 2 4 6 10
249..................................... 10077 4.2995 1 2 3 5 9
250..................................... 3178 4.9091 1 2 3 6 9
251..................................... 2090 3.2933 1 1 3 4 6
252..................................... 1 1.0000 1 1 1 1 1
253..................................... 17469 5.8164 2 3 4 7 11
254..................................... 9208 3.8588 1 2 3 5 7
255..................................... 1 2.0000 2 2 2 2 2
256..................................... 4600 5.7178 1 2 4 7 11
257..................................... 23640 3.4239 1 2 3 4 6
258..................................... 18784 2.4905 1 2 2 3 4
259..................................... 4010 3.5077 1 1 2 3 7
260..................................... 4868 1.8683 1 1 1 2 3
261..................................... 2334 2.3500 1 1 2 3 4
262..................................... 712 3.9284 1 1 2 5 8
263..................................... 29088 13.8669 4 6 10 16 28
264..................................... 3559 8.3442 2 4 6 10 17
265..................................... 4274 7.6467 1 2 5 9 16
266..................................... 2712 3.6855 1 1 3 5 7
267..................................... 222 4.0811 1 1 3 5 9
268..................................... 891 4.0000 1 1 2 4 9
269..................................... 10174 9.1235 2 3 7 12 18
270..................................... 3456 3.3958 1 1 2 4 8
271..................................... 21515 8.4984 3 4 7 10 15
272..................................... 5863 7.4481 2 3 6 9 14
273..................................... 1426 5.5035 2 2 4 7 11
274..................................... 2526 7.7458 2 3 5 9 15
275..................................... 250 3.5040 1 1 2 4 8
276..................................... 889 5.0472 1 2 4 6 9
277..................................... 79054 6.7240 3 4 5 8 12
278..................................... 26008 5.1420 2 3 4 6 9
279..................................... 5 4.8000 2 2 3 4 12
280..................................... 13098 5.1142 1 2 4 6 9
281..................................... 5890 3.6448 1 2 3 4 7
283..................................... 5233 5.4888 2 2 4 7 10
284..................................... 1755 3.8632 1 2 3 5 7
285..................................... 4886 13.5014 3 6 10 16 26
286..................................... 1918 8.7195 3 4 6 9 16
287..................................... 6284 13.3908 3 6 9 16 26
288..................................... 957 7.0449 2 4 5 7 11
289..................................... 4992 3.9732 1 2 2 4 8
290..................................... 8514 2.8404 1 1 2 3 5
291..................................... 86 1.7558 1 1 1 2 3
292..................................... 5046 12.6958 2 5 9 16 25
293..................................... 294 6.4456 1 3 5 8 14
294..................................... 86024 5.6681 2 3 4 7 10
295..................................... 3712 4.2826 1 2 3 5 8
296..................................... 218940 6.3561 2 3 5 8 12
[[Page 27563]]
297..................................... 31455 4.2781 1 2 3 5 8
298..................................... 95 3.0211 1 1 2 4 5
299..................................... 868 5.3652 1 2 4 7 10
300..................................... 14115 7.3032 2 3 6 9 14
301..................................... 2146 4.3877 1 2 3 6 9
302..................................... 7567 12.3190 6 7 9 14 21
303..................................... 18462 10.1938 4 6 8 12 18
304..................................... 12867 10.2970 3 5 7 13 21
305..................................... 2526 4.9097 1 3 4 6 9
306..................................... 11305 6.2204 2 2 4 8 13
307..................................... 2596 2.9819 1 2 2 3 5
308..................................... 9137 7.0113 1 2 5 9 15
309..................................... 3371 3.0009 1 1 2 4 6
310..................................... 28549 4.6077 1 2 3 6 9
311..................................... 9697 2.1734 1 1 2 3 4
312..................................... 1995 4.7895 1 2 3 6 10
313..................................... 745 2.2644 1 1 2 3 5
314..................................... 1 5.0000 5 5 5 5 5
315..................................... 27722 9.2695 1 2 6 12 20
316..................................... 69941 7.4958 2 3 6 9 15
317..................................... 779 2.8434 1 1 2 3 6
318..................................... 5981 7.1195 2 3 5 9 14
319..................................... 506 3.2174 1 1 2 4 7
320..................................... 169078 6.4297 2 3 5 8 11
321..................................... 25512 4.7020 2 3 4 6 8
322..................................... 81 4.3580 2 2 4 6 8
323..................................... 17690 3.5573 1 2 3 4 7
324..................................... 8755 2.0870 1 1 2 3 4
325..................................... 7381 4.5898 1 2 3 5 9
326..................................... 2186 3.4492 1 1 2 4 6
327..................................... 8 3.1250 1 2 2 2 4
328..................................... 817 4.2742 1 2 3 5 9
329..................................... 109 2.7523 1 1 2 3 5
330..................................... 1 1.0000 1 1 1 1 1
331..................................... 38181 6.1753 2 3 5 8 12
332..................................... 4687 3.8835 1 2 3 5 8
333..................................... 357 5.8319 1 3 4 7 13
334..................................... 19011 6.0503 3 4 5 7 9
335..................................... 9821 4.5786 2 3 4 6 7
336..................................... 60748 4.1251 1 2 3 5 8
337..................................... 38538 2.6717 1 2 2 3 4
338..................................... 4813 5.2703 1 2 3 6 11
339..................................... 2302 4.9392 1 2 3 6 10
340..................................... 2 3.0000 1 1 5 5 5
341..................................... 6427 3.2367 1 1 2 4 6
342..................................... 224 4.0089 1 1 2 5 8
344..................................... 3820 3.4652 1 1 2 4 7
345..................................... 1355 3.9734 1 2 3 4 9
346..................................... 5344 6.7500 1 3 5 8 14
347..................................... 418 3.3349 1 1 2 4 7
348..................................... 3021 4.8875 1 2 4 6 9
349..................................... 684 2.9956 1 1 2 4 6
350..................................... 6884 4.7451 2 3 4 6 8
352..................................... 576 3.9392 1 2 3 5 8
353..................................... 2621 8.3564 3 5 6 10 15
354..................................... 9693 6.3330 3 4 5 7 11
355..................................... 5607 3.8639 2 3 4 4 6
356..................................... 28647 3.0247 1 2 3 4 5
357..................................... 6526 9.8462 4 5 8 12 18
358..................................... 26797 4.7425 2 3 4 5 8
359..................................... 27392 3.2715 2 3 3 4 5
360..................................... 16717 3.5393 1 2 3 4 6
361..................................... 618 3.4644 1 1 2 4 7
363..................................... 4355 3.4953 1 2 2 3 6
364..................................... 1778 3.6310 1 1 2 5 8
365..................................... 2396 8.1123 2 3 5 10 18
366..................................... 4471 7.6741 2 3 5 10 16
367..................................... 545 3.3266 1 1 2 4 7
368..................................... 2285 6.9190 2 3 5 9 13
369..................................... 2409 3.7410 1 1 3 5 7
[[Page 27564]]
370..................................... 1083 5.5568 3 3 4 5 9
371..................................... 950 3.5874 2 3 3 4 5
372..................................... 809 3.3498 1 2 2 3 6
373..................................... 3637 1.9249 1 1 2 2 3
374..................................... 116 2.3621 1 2 2 2 3
375..................................... 5 2.2000 1 1 2 3 4
376..................................... 151 3.4834 1 1 2 4 8
377..................................... 26 3.2308 1 1 1 3 8
378..................................... 163 2.9755 1 2 3 3 5
379..................................... 309 2.9256 1 1 2 3 5
380..................................... 71 2.3239 1 1 2 3 4
381..................................... 194 2.2835 1 1 1 2 5
382..................................... 47 1.6596 1 1 1 1 3
383..................................... 1455 4.0460 1 2 3 5 8
384..................................... 123 3.3496 1 1 1 3 7
385..................................... 3 17.0000 1 1 1 49 49
389..................................... 24 10.6667 3 4 8 10 18
390..................................... 10 5.0000 1 2 3 6 9
392..................................... 2467 11.6700 4 6 8 15 24
394..................................... 1642 7.8831 1 2 5 9 16
395..................................... 65671 5.3672 1 2 4 7 10
396..................................... 18 3.9444 1 1 3 7 8
397..................................... 15421 6.0683 2 3 4 7 12
398..................................... 16601 6.5794 2 3 5 8 12
399..................................... 1424 4.4347 1 2 4 6 8
400..................................... 7468 10.3293 2 4 7 13 23
401..................................... 6365 12.3829 2 5 9 16 25
402..................................... 1542 4.6984 1 1 3 6 10
403..................................... 34765 9.2628 2 4 7 12 19
404..................................... 3944 5.0822 1 2 4 7 10
406..................................... 3264 11.1468 3 5 8 14 23
407..................................... 723 4.9267 1 2 4 6 9
408..................................... 2949 8.2035 1 2 5 10 18
409..................................... 5649 6.6516 2 3 4 6 14
410..................................... 85871 3.3540 1 2 3 4 5
411..................................... 50 2.5600 1 1 2 3 7
412..................................... 35 3.0857 1 1 2 4 8
413..................................... 8422 8.2992 2 3 6 10 17
414..................................... 797 5.2070 1 2 4 7 11
415..................................... 38804 15.6974 4 7 12 19 31
416..................................... 192133 8.2122 2 4 7 10 15
417..................................... 45 4.6222 1 2 4 7 10
418..................................... 18663 6.7433 2 3 5 8 13
419..................................... 15677 5.6580 2 3 4 7 10
420..................................... 2871 4.3006 2 2 4 5 8
421..................................... 11386 4.6473 2 2 4 6 8
422..................................... 89 3.6854 1 2 3 4 7
423..................................... 9118 8.6534 2 4 6 10 18
424..................................... 1990 17.7397 3 6 12 20 34
425..................................... 15247 4.8955 1 2 3 6 10
426..................................... 4721 5.4938 1 2 4 7 11
427..................................... 1773 5.2775 1 2 4 7 11
428..................................... 904 8.4303 1 3 5 10 18
429..................................... 38861 8.9079 2 3 6 10 17
430..................................... 53430 9.7495 2 4 7 12 19
431..................................... 190 7.4632 1 3 5 9 14
432..................................... 430 6.3395 1 2 4 6 11
433..................................... 7843 3.4051 1 1 2 4 7
434..................................... 20810 5.8148 2 3 4 7 11
435..................................... 15477 4.8166 1 3 4 6 8
436..................................... 2915 14.5413 4 8 14 21 28
437..................................... 14205 10.8943 4 6 10 14 20
439..................................... 867 8.9262 2 3 6 11 18
440..................................... 4751 9.7838 2 3 6 12 21
441..................................... 611 4.4386 1 1 2 4 7
442..................................... 13818 8.7372 1 3 6 11 18
443..................................... 3299 3.5335 1 1 2 5 7
444..................................... 3319 5.3203 1 3 4 6 10
445..................................... 1321 3.7858 1 2 3 5 7
446..................................... 1 1.0000 1 1 1 1 1
[[Page 27565]]
447..................................... 3816 2.7953 1 1 2 3 5
448..................................... 84 1.0000 1 1 1 1 1
449..................................... 28775 4.4101 1 2 3 5 9
450..................................... 6807 2.3364 1 1 2 3 5
451..................................... 7 6.1429 2 3 4 5 7
452..................................... 19382 5.4066 1 2 4 6 11
453..................................... 3636 3.1876 1 1 2 4 6
454..................................... 5132 5.1046 1 2 3 6 10
455..................................... 1092 2.8333 1 1 2 3 5
456..................................... 194 8.3711 1 1 4 9 21
457..................................... 127 4.7953 1 1 2 5 10
458..................................... 1550 16.9387 4 7 13 22 35
459..................................... 533 10.3471 2 4 7 13 22
460..................................... 2303 6.6309 1 3 5 8 13
461..................................... 3040 4.8862 1 1 2 5 12
462..................................... 9360 13.7955 5 6 12 18 26
463..................................... 11987 5.1410 1 2 4 6 10
464..................................... 3079 3.7347 1 2 3 5 7
465..................................... 197 3.9086 1 1 2 4 7
466..................................... 1838 4.6366 1 1 2 4 10
467..................................... 1722 4.1057 1 1 2 4 8
468..................................... 56350 15.2546 3 7 12 19 30
471..................................... 9111 8.0289 4 5 6 9 13
472..................................... 150 30.6667 2 9 28 41 62
473..................................... 8211 14.3041 2 4 8 21 35
475..................................... 89514 12.1394 2 5 10 16 24
476..................................... 6875 13.7876 3 7 11 17 25
477..................................... 30427 9.1915 1 3 7 12 19
478..................................... 117755 8.2916 1 3 6 10 17
479..................................... 17758 4.5591 1 2 4 6 9
480..................................... 359 29.7159 10 13 22 37 61
481..................................... 177 32.0678 19 22 28 35 52
482..................................... 6754 14.9011 5 8 11 17 28
483..................................... 36200 45.7958 15 23 37 56 84
484..................................... 327 15.3364 2 6 11 21 32
485..................................... 3165 11.5893 4 6 9 13 21
486..................................... 2045 13.3482 1 6 11 18 28
487..................................... 3765 8.8770 1 3 7 11 17
488..................................... 1593 17.5267 5 8 13 22 35
489..................................... 17612 10.3989 2 4 7 13 22
490..................................... 4999 6.5719 1 2 4 8 14
491..................................... 9441 4.2777 2 3 3 5 7
492..................................... 2029 17.3834 3 5 10 28 37
493..................................... 52260 5.8809 1 2 5 8 11
494..................................... 27127 2.4245 1 1 2 3 5
495..................................... 107 23.7944 10 13 18 29 41
----------------
10571233
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8a.--Statewide Average Operating Cost-To-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) April 1996
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................... 0.421 0.476
ALASKA................................................ 0.505 0.795
ARIZONA............................................... 0.426 0.567
ARKANSAS.............................................. 0.539 0.501
CALIFORNIA............................................ 0.408 0.544
COLORADO.............................................. 0.509 0.595
CONNECTICUT........................................... 0.553 0.551
DELAWARE.............................................. 0.533 0.523
DISTRICT OF COLUMBIA.................................. 0.525 .......
FLORIDA............................................... 0.414 0.414
GEORGIA............................................... 0.527 0.532
HAWAII................................................ 0.484 0.567
IDAHO................................................. 0.563 0.639
ILLINOIS.............................................. 0.490 0.588
INDIANA............................................... 0.565 0.628
IOWA.................................................. 0.546 0.685
KANSAS................................................ 0.457 0.651
KENTUCKY.............................................. 0.507 0.562
LOUISIANA............................................. 0.478 0.538
MAINE................................................. 0.589 0.590
MARYLAND.............................................. 0.765 0.816
MASSACHUSETTS......................................... 0.579 0.600
MICHIGAN.............................................. 0.514 0.619
MINNESOTA............................................. 0.565 0.655
MISSISSIPPI........................................... 0.524 0.527
MISSOURI.............................................. 0.460 0.532
MONTANA............................................... 0.513 0.622
NEBRASKA.............................................. 0.526 0.696
NEVADA................................................ 0.322 0.550
NEW HAMPSHIRE......................................... 0.597 0.615
NEW JERSEY............................................ 0.479 .......
NEW MEXICO............................................ 0.484 0.546
NEW YORK.............................................. 0.595 0.684
NORTH CAROLINA........................................ 0.546 0.501
[[Page 27566]]
NORTH DAKOTA.......................................... 0.651 0.693
OHIO.................................................. 0.567 0.606
OKLAHOMA.............................................. 0.494 0.572
OREGON................................................ 0.573 0.649
PENNSYLVANIA.......................................... 0.437 0.585
PUERTO RICO........................................... 0.495 0.642
RHODE ISLAND.......................................... 0.587 .......
SOUTH CAROLINA........................................ 0.476 0.497
SOUTH DAKOTA.......................................... 0.571 0.629
TENNESSEE............................................. 0.534 0.577
TEXAS................................................. 0.463 0.565
UTAH.................................................. 0.578 0.665
VERMONT............................................... 0.638 0.596
VIRGINIA.............................................. 0.499 0.538
WASHINGTON............................................ 0.636 0.686
WEST VIRGINIA......................................... 0.579 0.541
WISCONSIN............................................. 0.607 0.686
WYOMING............................................... 0.495 0.735
------------------------------------------------------------------------
Table 8b.--Statewide Average Capital Cost-To-Charge Ratios (Case
Weighted) April 1996
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA........................................................ 0.055
ALASKA......................................................... 0.077
ARIZONA........................................................ 0.051
ARKANSAS....................................................... 0.055
CALIFORNIA..................................................... 0.040
COLORADO....................................................... 0.053
CONNECTICUT.................................................... 0.037
DELAWARE....................................................... 0.054
DISTRICT OF COLUMBIA........................................... 0.042
FLORIDA........................................................ 0.051
GEORGIA........................................................ 0.052
HAWAII......................................................... 0.051
IDAHO.......................................................... 0.067
ILLINOIS....................................................... 0.045
INDIANA........................................................ 0.059
IOWA........................................................... 0.062
KANSAS......................................................... 0.055
KENTUCKY....................................................... 0.056
LOUISIANA...................................................... 0.069
MAINE.......................................................... 0.045
MARYLAND....................................................... 0.013
MASSACHUSETTS.................................................. 0.060
MICHIGAN....................................................... 0.053
MINNESOTA...................................................... 0.055
MISSISSIPPI.................................................... 0.056
MISSOURI....................................................... 0.053
MONTANA........................................................ 0.064
NEBRASKA....................................................... 0.058
NEVADA......................................................... 0.034
NEW HAMPSHIRE.................................................. 0.065
NEW JERSEY..................................................... 0.045
NEW MEXICO..................................................... 0.055
NEW YORK....................................................... 0.059
NORTH CAROLINA................................................. 0.050
NORTH DAKOTA................................................... 0.074
OHIO........................................................... 0.056
OKLAHOMA....................................................... 0.058
OREGON......................................................... 0.051
PENNSYLVANIA................................................... 0.045
PUERTO RICO.................................................... 0.078
RHODE ISLAND................................................... 0.039
SOUTH CAROLINA................................................. 0.053
SOUTH DAKOTA................................................... 0.064
TENNESSEE...................................................... 0.057
TEXAS.......................................................... 0.055
UTAH........................................................... 0.055
VERMONT........................................................ 0.050
VIRGINIA....................................................... 0.058
WASHINGTON..................................................... 0.063
WEST VIRGINIA.................................................. 0.060
WISCONSIN...................................................... 0.048
WYOMING........................................................ 0.067
------------------------------------------------------------------------
Appendix A--Regulatory Impact Analysis
I. Introduction
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA)(5 U.S.C. 601
through 612), unless the Secretary certifies that a proposed rule would
not have a significant economic impact on a substantial number of small
entities. For purposes of the RFA, we consider all hospitals to be
small entities.
Also, section 1102(b) of the Social Security Act (the Act) requires
the Secretary to prepare a regulatory impact analysis for any proposed
rule that may have a significant impact on the operations of a
substantial number of small rural hospitals. Such an analysis must
conform to the provisions of section 603 of the RFA. With the exception
of hospitals located in certain New England counties, for purposes of
section 1102(b) of the Act, we define a small rural hospital as a
hospital with fewer than 100 beds that is located outside of a
Metropolitan Statistical Area (MSA) or New England County Metropolitan
Area (NECMA). Section 601(g) of the Social Security Amendments of 1983
(Public Law 98-21) designated hospitals in certain New England counties
as belonging to the adjacent NECMA. Thus, for purposes of the
prospective payment system, we classify these hospitals as urban
hospitals.
It is clear that the changes being proposed in this document would
affect both a substantial number of small rural hospitals as well as
other classes of hospitals, and the effects on some may be significant.
Therefore, the discussion below, in combination with the rest of this
proposed rule, constitutes a combined regulatory impact analysis and
regulatory flexibility analysis.
II. Objectives
The primary objective of the prospective payment system is to
create incentives for hospitals to operate efficiently and minimize
unnecessary costs while at the same time ensuring that payments are
sufficient to adequately compensate hospitals for their legitimate
costs. In addition, we share national goals of deficit reduction and
restraints on government spending in general.
We believe the proposed changes would further each of these goals
while maintaining the financial viability of the hospital industry and
ensuring access to high quality health care for Medicare beneficiaries.
We expect that these proposed changes would ensure that the outcomes of
this payment system are, in general, reasonable and equitable while
avoiding or minimizing unintended adverse consequences.
III. Limitations of Our Analysis
As has been the case in previously published regulatory impact
analyses, the following quantitative analysis presents the projected
effects of our proposed policy changes, as well as statutory changes
effective for FY 1997, on various hospital groups. We estimate the
effects of individual policy changes by estimating payments per case
while holding all other payment policies constant. We use the best data
available, but we do not attempt to predict behavioral responses to our
policy changes, and we do not make adjustments for future changes in
such variables as admissions, lengths of stay, or case mix. As we have
done in previous proposed rules, we are soliciting comments and
information about the anticipated effects of these changes on
hospitals, and our methodology for estimating them.
IV. Hospitals Included In and Excluded From the Prospective Payment
System
The prospective payment systems for hospital inpatient operating
and capital-related costs encompass nearly all general, short-term,
acute care hospitals that participate in the Medicare program. There
were 46 Indian Health Service hospitals in our data base, which we
excluded from the analysis due to the special characteristics of the
prospective payment method for these hospitals. Among other short-term,
acute care hospitals, only the 50 such hospitals in Maryland remain
excluded from the prospective payment system under the waiver at
section 1814(b)(3) of the Act. Thus, as of April 1996, we have included
5,130 hospitals in our analysis. This represents about 82 percent of
all
[[Page 27567]]
Medicare-participating hospitals. The majority of this impact analysis
focuses on this set of hospitals.
The remaining 18 percent are specialty hospitals that are excluded
from the prospective payment system and continue to be paid on the
basis of their reasonable costs (subject to a rate-of-increase ceiling
on their inpatient operating costs per discharge). These hospitals
include psychiatric, rehabilitation, long-term care, children's, and
cancer hospitals. The impacts of our proposed policy changes on these
hospitals are discussed below.
V. Impact on Excluded Hospitals and Units
As of April 1996, there were 1,141 specialty hospitals excluded
from the prospective payment system and instead paid on a reasonable
cost basis subject to the rate-of-increase ceiling under Sec. 413.40.
In addition, there were 2,258 psychiatric and rehabilitation units in
hospitals otherwise subject to the prospective payment system. These
excluded units are also paid in accordance with Sec. 413.40.
In accordance with section 1886(b)(3)(B)(ii)(V) of the Act, the
update factor applicable to the rate-of-increase limit for excluded
hospitals and units for FY 1997 would be 1.7 percent (excluded hospital
market basket minus 1.0 percentage points), adjusted to account for the
relationship between the hospital's allowable operating cost per case
and its target amounts.
The impact on excluded hospitals and units of the proposed update
in the rate-of-increase limit depends on the cumulative cost increases
experienced by each excluded hospital and excluded unit since its
applicable base period. For excluded hospitals and units that have
maintained their cost increases at a level below the percentage
increases in the rate-of-increase limits since their base period, the
major effect will be on the level of incentive payments these hospitals
and units receive. Conversely, for excluded hospitals and units with
per-case cost increases above the cumulative update in their rate-of-
increase limit, the major effect will be the amount of excess costs
that the hospitals would have to absorb.
In this context, we note that, under Sec. 413.40(d)(3), an excluded
hospital or unit whose costs exceed the rate-of-increase limit is
allowed to receive the lower of its rate-of-increase ceiling plus 50
percent of reasonable costs in excess of the ceiling, or 110 percent of
its ceiling. In addition, under the various provisions set forth in
Sec. 413.40, excluded hospitals and units can obtain payment
adjustments for significant, justifiable, increases in operating costs
that exceed the limit. At the same time, however, by generally limiting
payment increases, we continue to provide an incentive for excluded
hospitals and units to restrain the growth in their spending for
patient services.
VI. Quantitative Impact Analysis of the Proposed Policy Changes Under
the Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
In this proposed rule, we are announcing policy changes and payment
rate updates for the prospective payment systems for operating and
capital-related costs. We have prepared separate analyses of the
proposed changes to each system, beginning with changes to the
operating prospective payment system.
The data used in developing the quantitative analyses presented
below are taken from the FY 1995 MedPAR file and the most current
provider-specific file that is used for payment purposes. Although the
analyses of the changes to the operating prospective payment system do
not incorporate cost data, the most recently available hospital cost
report data were used to create some of the variables by which
hospitals are categorized. Our analysis has several qualifications.
First, we do not make adjustments for behavioral changes that hospitals
may adopt in response to these proposed policy changes. Second, due to
the interdependent nature of the prospective payment system, it is very
difficult to precisely quantify the impact associated with each
proposed change. Third, we draw upon various sources for the data used
to categorize hospitals in the tables. In some cases, particularly the
number of beds, there is a fair degree of variation in the data from
different sources. We have attempted to construct these variables with
the best available source overall. For individual hospitals, however,
some miscategorizations are possible.
Using cases in the FY 1995 MedPAR file, we simulated payments under
the operating prospective payment system given various combinations of
payment parameters. Any short-term, acute care hospitals not paid under
the general prospective payment systems (Indian Health Service
hospitals and hospitals in Maryland) are excluded from the simulations.
Payments under the capital prospective payment system, or payments for
costs other than inpatient operating costs, are not analyzed here.
Estimated payment impacts of proposed FY 1997 changes to the capital
prospective payment system are discussed below in section VII of this
Appendix.
The proposed changes discussed separately below are the following:
The effects of the annual reclassification of diagnoses
and procedures and the recalibration of the diagnosis-related group
(DRG) relative weights required by section 1886(d)(4)(C) of the Act.
The effects of changes in hospitals' wage index values
reflecting the wage index update (FY 1993 data).
The effects of geographic reclassifications by the
Medicare Geographic Classification Review Board (MGCRB) that will be
effective in FY 1997.
The effects of phasing out payments for extraordinarily
lengthy cases (day outlier cases) with a corresponding increase in
payments for extraordinarily costly cases (cost outliers), in
accordance with section 1886(d)(5)(A)(v) of the Act.
The total change in payments based on FY 1997 policies
relative to payments based on FY 1996 policies.
To illustrate the impacts of the FY 1997 proposed changes, our
analysis begins with an FY 1997 baseline simulation model using: the FY
1996 GROUPER (version 13.0); the FY 1996 wage indexes; no MGCRB
reclassifications; and current outlier policy (50 percent phase out of
day outlier payments). Outlier payments are assumed to be 5.1 percent
of total DRG payments.
Each policy change is then added incrementally to this baseline
model, finally arriving at an FY 1997 model incorporating all of the
proposed changes. This allows us to isolate the effects of each
proposed change.
Our final comparison illustrates the percent change in payments per
case from FY 1996 to FY 1997. Four factors not displayed in the
previous five columns have significant impacts here. First is the
update to the standardized amounts. In accordance with section
1886(d)(3)(A)(iv) of the Act, we are proposing to update the large
urban and the other areas average standardized amounts for FY 1997
using the most recently forecasted hospital market basket increase for
FY 1997 of 2.7 percent, minus 0.5 percentage points. Thus, the update
to the large urban and other areas standardized amounts is 2.2 percent.
Similarly, section 1886(b)(3)(C)(ii) of the Act provides that the
update factor applicable to the hospital-specific rates for sole
community hospitals (SCHs) and essential access community hospitals
(EACHs) (which are treated as SCHs for
[[Page 27568]]
payment purposes) is also the market basket increase minus 0.5 percent,
or 2.2 percent.
A second significant factor impacting changes in hospitals'
payments per case from FY 1996 to FY 1997 is a change in MGCRB
reclassification status from one year to the next. That is, hospitals
reclassified in FY 1996 that are no longer reclassified in FY 1997 may
have a negative payment impact going from FY 1996 to FY 1997;
conversely, hospitals not reclassified in FY 1996 that are reclassified
in FY 1997 may have a positive impact. In some cases these impacts can
be quite substantial, so if a relatively small number of hospitals in a
particular category lose their reclassification status, the percentage
increase in payments for the category may be below the national mean.
A third significant factor is that we currently estimate that
actual outlier payments during FY 1996 will be 4.2 percent of actual
total DRG payments. When the FY 1996 final rule was published, we
projected FY 1996 outlier payments would be 5.1 percent of total DRG
payments, and the standardized amounts were reduced correspondingly.
The effects of the lower than expected outlier payments during FY 1996
(as discussed in the Addendum to this proposed rule) are reflected in
the analyses below comparing our current estimates of FY 1996 payments
per case to estimated FY 1997 payments per case.
Finally, the regional floor provision (section
1886(d)(1)(A)(iii)(II) of the Act) expires effective with discharges
occurring on or after October 1, 1996. Under this provision (applicable
during FY 1996), hospitals within any census division having a regional
standardized amount greater than the national standardized amount
(large urban or other, depending on which amount was applicable)
received a blend of 85 percent of the national amount and 15 percent of
the regional amount. Hospitals in census divisions where the regional
floor was applicable during FY 1996 will be negatively impacted by its
expiration when comparing FY 1996 to FY 1997.
Table I demonstrates the results of our analysis. The table
categorizes hospitals by various geographic and special payment
consideration groups to illustrate the varying impacts on different
types of hospitals. The top row of the table shows the overall impact
on the 5,130 hospitals included in the analysis. This is 77 fewer
hospitals than were included in the impact analysis in the FY 1996
final rule (60 FR 45924). Data for 107 hospitals that were included in
last year's analysis were not available for analysis this year;
however, data were available this year for 30 hospitals for which data
were not available last year.
The next four rows of Table I contain hospitals categorized
according to their geographic location (all urban, which is further
divided into large urban and other urban, or rural). There are 2,878
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,597 hospitals located in large urban
areas (populations over 1 million), and 1,281 hospitals in other urban
areas (populations of 1 million or fewer). In addition, there are 2,252
hospitals in rural areas. The next two groupings are by bed size
categories, shown separately for urban and rural hospitals. The final
groupings by geographic location are by census divisions, also shown
separately for urban and rural hospitals.
The second part of Table I shows hospital groups based on
hospitals' FY 1997 payment classifications, including any
reclassifications under section 1886(d)(10) of the Act. For example,
the rows labeled urban, large urban, other urban, and rural, show the
numbers of hospitals being paid based on these categorizations (after
consideration of geographic reclassifications), are 2,978, 1,793,
1,185, and 2,152, respectively.
The next three groupings examine the impacts of the proposed
changes on hospitals grouped by whether or not they have residency
programs (teaching hospitals that receive an indirect medical education
(IME) adjustment), receive disproportionate share (DSH) payments, or
some combination of these two adjustments. There are 4,057 nonteaching
hospitals in our analysis, 841 teaching hospitals with fewer than 100
residents, and 232 teaching hospitals with 100 or more residents.
In the DSH categories, hospitals are grouped according to their DSH
payment status, and whether they are considered urban or rural after
MGCRB reclassifications. Hospitals in the rural DSH categories,
therefore, represent hospitals that were not reclassified for purposes
of the standardized amount. (They may, however, have been reclassified
for purposes of the wage index.) The next category groups hospitals
considered urban after geographic reclassification, in terms of whether
they receive the IME adjustment, the DSH adjustment, both, or neither.
The next four rows examine the impacts of the proposed changes on
rural hospitals by special payment groups (SCHs, rural referral centers
(RRCs), and EACHs), as well as rural hospitals not receiving a special
payment designation. Rural hospitals reclassified for FY 1997 for
purposes of the standardized amount are not included here.
The RRCs (90), SCH/EACHs (641), and SCH/EACH and RRCs (39) shown
here were not reclassified for purposes of the standardized amount.
There are four EACHs included in our analysis and five EACH/RRCs.
There are two RRCs and three SCHs that will be reclassified for the
standardized amount in FY 1997 that, therefore, are not included in
these rows. There are significantly fewer reclassifications among these
groups than there were in FY 1996, owing to the new criterion under
Sec. 412.230(a)(5)(ii) that a hospital may not be reclassified for
purposes of the standardized amount if the area to which the hospital
seeks reclassification does not have a higher standardized amount than
that currently received by the hospital. (See the September 1, 1995
final rule (60 FR 45799).) Before this change (effective with
reclassifications for FY 1997), some rural hospitals reclassified to
other urban areas in order to qualify for urban DSH payments. For other
rural hospitals that already qualified for DSH payments, the urban
designation enabled them to qualify for a higher DSH adjustment than
they would receive as a rural hospital.
The next two groupings are based on type of ownership and the
hospital's Medicare utilization expressed as a percent of total patient
days. These data are taken primarily from the FY 1994 Medicare cost
report files, if available (otherwise FY 1993 data are used). Data
needed to calculate Medicare utilization percentages were unavailable
for 131 hospitals. For the most part, these are either new hospitals or
hospitals filing manual cost reports that are not yet entered into the
data base.
The next series of groupings concern the geographic
reclassification status of hospitals. The first three groupings display
hospitals that were reclassified by the MGCRB for either FY 1996 or FY
1997, or for both years, by urban/rural status. The next rows
illustrate the overall number of FY 1997 reclassifications, as well as
the numbers of reclassified hospitals grouped by urban and rural
location. The final row in Table I contains hospitals located in rural
counties but deemed to be urban under section 1886(d)(8)(B) of the Act.
[[Page 27569]]
Table I.--Impact Analysis of Changes for FY 1997 Operating Prospective Payment System
[Percent changes in payments per case]
Day outlier
Number of DRG New wage MGCRB policy All FY 97
hosps.\1\ recalibration data \3\ reclassification changes \5\ changes \6\
(0) (1) (2) (3) (4) (5)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(By Geographic Location)
--------------------------------------------------------------------------------------------------------------------------------------------------------
All hospitals................................................ 5,130 0.1 -0.1 0.0 0.0 3.1
Urban hospitals.............................................. 2,878 0.1 0.0 -0.4 -0.1 3.2
Large urban.............................................. 1,597 0.1 0.0 -0.5 -0.2 3.1
Other urban.............................................. 1,281 0.1 -0.1 -0.2 0.1 3.3
Rural hospitals.............................................. 2,252 0.0 -0.1 2.3 0.1 2.7
Bed size (urban):
0-99 beds................................................ 716 0.0 -0.3 -0.5 0.2 3.0
100-199 beds............................................. 938 0.0 -0.2 -0.4 0.1 2.9
200-299 beds............................................. 577 0.1 -0.1 -0.4 0.0 3.1
300-499 beds............................................. 479 0.1 0.0 -0.4 -0.1 3.4
500 or more beds......................................... 168 0.1 0.1 -0.2 -0.4 3.4
Bed size (rural):
0-49 beds................................................ 1,173 -0.1 0.0 0.0 0.1 2.8
50-99 beds........................................... 663 -0.1 -0.1 1.1 0.2 2.8
100-149 beds......................................... 241 0.0 -0.1 3.1 0.2 2.9
150-199 beds......................................... 99 0.0 -0.1 2.8 0.1 2.8
200 or more beds..................................... 76 0.1 -0.2 4.9 0.1 2.2
Urban by census division:
New England.............................................. 160 0.1 0.0 -0.1 -0.1 2.4
Middle Atlantic.......................................... 434 0.1 0.6 -0.3 -1.1 3.5
South Atlantic........................................... 419 0.1 -0.2 -0.5 0.1 3.3
East North Central....................................... 483 0.1 0.3 -0.2 0.2 2.9
East South Central....................................... 163 0.1 -0.3 -0.5 0.2 3.4
West North Central....................................... 193 0.1 -0.4 -0.5 0.3 3.4
West South Central....................................... 375 0.1 -0.4 -0.5 0.4 3.6
Mountain................................................. 125 0.2 -0.4 -0.4 0.3 3.3
Pacific.................................................. 478 0.1 -0.5 -0.4 0.2 2.9
Puerto Rico.............................................. 48 -0.1 -0.7 -0.5 0.0 2.6
Rural by census division:
New England.............................................. 53 0.1 -1.0 2.0 0.3 2.1
Middle Atlantic.......................................... 85 0.1 -0.5 0.8 -0.2 1.9
South Atlantic........................................... 297 0.0 -0.5 3.1 0.1 2.6
East North Central....................................... 304 0.1 0.2 2.1 0.2 2.9
East South Central....................................... 278 -0.1 0.2 2.5 0.2 2.2
West North Central....................................... 525 0.0 -0.1 2.1 0.2 2.8
West South Central....................................... 351 -0.1 0.2 3.1 0.2 3.2
Mountain................................................. 213 0.1 -0.2 0.8 0.1 3.0
Pacific.................................................. 141 0.1 0.5 2.4 0.2 4.0
Puerto Rico.............................................. 5 -0.2 -2.1 2.7 -0.1 3.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
(by payment categories)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Urban hospitals.............................................. 2,978 0.1 0.0 -0.3 -0.1 3.2
Large urban.............................................. 1,793 0.1 0.0 -0.2 -0.2 3.2
Other urban.............................................. 1,185 0.1 -0.1 -0.4 0.1 3.3
Rural hospitals.............................................. 2,152 0.0 -0.1 1.9 0.1 2.6
Teaching status:
Non-teaching............................................. 4,057 0.0 -0.2 0.3 0.2 3.1
Less than 100 res........................................ 841 0.1 0.0 -0.4 0.0 3.2
100+ residents........................................... 232 0.1 0.2 -0.1 -0.5 3.2
Disproportionate Share Hospitals (DSH)
Non-DSH.................................................. 3,200 0.1 -0.2 0.2 0.1 3.2
Urban DSH:
100 beds or more..................................... 1,410 0.0 0.0 -0.3 -0.2 3.2
Fewer than 100 beds.................................. 111 -0.3 -0.4 -0.5 0.3 2.5
Rural DSH:
Sole community (SCH)................................. 146 -0.1 -0.1 0.2 0.0 3.3
Referral centers (RRC)............................... 25 0.0 -0.1 3.9 -0.1 3.7
Over 65.................................................. 1,353 0.0 -0.1 0.1 0.1 3.1
Unknown.................................................. 131 -0.1 0.9 -0.4 -1.4 3.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hospitals Reclassified by the Medicare Geographic Review Board
--------------------------------------------------------------------------------------------------------------------------------------------------------
Reclassification status during FY96 and FY97
Reclassified during both FY96 and FY97................... 381 0.1 0.1 5.9 0.0 3.1
[[Page 27570]]
Urban................................................ 133 0.1 0.3 3.6 -0.2 3.4
Rural................................................ 248 0.0 -0.2 9.1 0.1 2.8
Reclassified during FY97 only............................ 103 0.1 0.3 3.5 -0.4 8.6
Urban................................................ 34 0.2 0.4 2.4 -0.5 8.0
Rural................................................ 69 0.0 -0.2 7.1 0.1 10.5
Reclassified during FY96 only 251 0.1 -0.6 -1.3 0.1 -0.5
Urban................................................ 88 0.1 -0.9 -2.0 0.0 0.8
Rural................................................ 163 0.0 -0.2 -0.4 0.2 -2.1
FY 97 Reclassifications:
All reclassified hosp.................................... 484 0.1 0.1 5.3 -0.1 4.3
Stand. amount only................................... 120 0.1 0.0 1.7 0.1 3.1
Wage index only...................................... 274 0.1 -0.3 8.1 -0.1 3.9
Both................................................. 90 0.1 0.8 4.4 -0.2 5.9
Nonreclassified...................................... 4,619 0.1 -0.1 -0.6 0.0 3.0
All urban reclass........................................ 167 0.1 0.3 3.3 -0.3 4.6
Stand. amount only................................... 63 0.1 0.1 0.9 0.0 3.3
Wage index only...................................... 30 0.2 -0.6 6.7 -0.6 4.5
Both................................................. 74 0.1 0.9 3.1 -0.2 5.6
Nonreclassified...................................... 2,711 0.1 -0.1 -0.6 -0.1 3.1
All rural reclass........................................ 317 0.0 -0.2 8.8 0.1 3.8
Stand. amount only................................... 57 0.0 -0.3 4.6 0.3 2.7
Wage index only...................................... 244 0.0 -0.1 8.8 0.1 3.6
Both................................................. 16 0.1 -0.4 18.8 0.2 9.1
Nonreclassified...................................... 1,908 0.0 -0.1 -0.4 0.1 2.2
Other reclassifed:
Hospitals (section 1886(d)(8)(B))........................ 27 0.1 -0.1 0.8 0.2 3.1
\1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the
national total. Discharge data are from FY 1995, and hospital cost report data are from reporting periods beginning in FY 1993 and FY 1994.
\2\ This column displays the payment impacts of the recalibration of the DRG weights, based on FY 1995 MedPAR data and the DRG classification changes,
in accordance with section 1886(d)(4)(C) of the Act.
\3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1993 cost reports. The percentage
changes displayed here reflect the impacts of the wage and recalibration budget neutrality factor (0.998509).
\4\ Shown here are the combined effects of geographic reclassification by the Medicare Geographic Classification Review Board (MGCRB). The effects shown
here demonstrate the FY 1997 payment impacts of going from no reclassifications to the reclassifications scheduled to be in effect for FY 1997.
Reclassification for prior years has no bearing on the payment impacts shown here.
\5\ This column illustrates the payment impacts of changes in outlier payments, in accordance with section 1886(d)(5) of the Act.
\6\ This column shows changes in payments from FY 1996 to FY 1997. It incorporates all of the changes displayed in columns 1 through 5. It also displays
the impacts of the updates to the FY 1997 standardized amounts, changes in hospitals' reclassification status in FY 1997 compared to FY 1996, the
expiration of the regional floor provision at section 1886(d)(1)(A)(iii)(II) of the Act, and the difference in outlier payments from FY 1996 to FY
1997. The sum of the first five columns plus these effects may be different from the percentage changes shown here due to changes in hospitals'
geographic reclassification status from FY 1996 to FY 1997, rounding errors and interactive effects.
B. The Impact of the Proposed Changes to the DRG Classifications and
Relative Weights (Column 1)
In column 1 of Table I, we present the combined effects of the DRG
reclassifications and recalibration, as discussed in section II of the
preamble to this proposed rule. Section 1886(d)(4)(C)(i) of the Act
requires us each year to make appropriate classification changes and to
recalibrate the DRG weights in order to reflect changes in treatment
patterns, technology, and any other factors that may change the
relative use of hospital resources.
The impact of reclassifications and recalibration on aggregate
payments is required by section 1886(d)(4)(C)(iii) of the Act to be
budget neutral. In addition, section 1886(d)(3)(E) specifies that any
updates or adjustments to the wage index are budget neutral. As pointed
out in the Addendum to this proposed rule, we compared aggregate
payments using the FY 1996 DRG relative weights and the wage index
effective October 1, 1995 to aggregate payments using the proposed FY
1997 DRG relative weights and wage index. Based on this comparison, we
computed a wage and recalibration budget neutrality factor of 0.998509.
In Table I, the combined overall impacts of the effects of both the DRG
reclassifications and recalibration and the updated wage index (the All
Hospitals row of columns 1 and 2) demonstrate that the net effect of
these changes are budget neutral. That is, the 0.1 percent increase for
all hospitals due to the DRG changes is negated by the 0.1 percent
decrease for all hospitals with the new wage data.
Consistent with the minor changes we are proposing for the FY 1997
GROUPER, the redistributional impacts across hospital groups are very
small (an increase of 0.1 for large and other urban hospitals). Among
other hospital categories, the net effects are slightly negative
changes for small (up to 99 beds) rural hospitals and slightly positive
changes for larger (over 200 beds) rural and urban hospitals.
The largest single effect on any of the hospital categories
examined is a 0.3 percent decrease in payments for smaller (100 or
fewer beds) urban and rural hospitals that receive DSH payments. We
note that the only other hospital category to experience a
[[Page 27571]]
decrease of more than 0.1 percent is rural hospitals in Puerto Rico.
We attribute these negative changes to the increasing gap between
the relative weights for medical, diagnostic, and less complicated
surgical DRGs and the weights for the more complicated surgical DRGs.
Since the cases associated with the former DRGs tend to be treated more
often in smaller hospitals with fewer resources available, lowering the
relative weights associated with those cases would disproportionately
affect these hospitals. In general, small hospitals that serve a
disproportionate share of low-income patients and hospitals in rural
Puerto Rico fit this definition. We note, however, that these negative
impacts are relatively minor and do not result solely from the limited
DRG revisions we are proposing for FY 1997.
C. The Impact of Updating the Wage Data (Column 2)
Section 1886(d)(3)(E) of the Act requires that, beginning October
1, 1993, we annually update the wage data used to calculate the wage
index. In accordance with this requirement, the proposed wage index for
FY 1997 is based on data submitted for hospital cost reporting periods
beginning on or after October 1, 1992 and before October 1, 1993. As
with the previous column, the impact of the new data on hospital
payments is isolated by holding the other payment parameters constant
in the two simulations. That is, column 2 shows the percentage changes
in payments when going from a model using the FY 1996 wage index before
geographic reclassifications based on FY 1992 wage data to a model
using the FY 1997 prereclassification wage index based on FY 1993 wage
data.
As noted above, to comply with the requirements that the DRG and
wage index changes be implemented in a budget neutral manner, we
compute a budget neutrality adjustment factor to apply to the
standardized amounts. The 0.1 percent decrease for all hospitals in
this column reflects the wage and recalibration budget neutrality
factor of 0.998509. This decrease, combined with the 0.1 percent
increase for all hospitals in column 1, demonstrates that the net
effect on aggregate payments of the proposed DRG and wage index changes
are budget neutral.
The results indicate that the new wage data do not have a
significant overall impact on hospital payments. (It should be noted
that the percentage changes attributed here to the new wage data are
generally reduced by 0.2 percentage points due to the budget neutrality
factor.) Thus, hospitals with significant changes in their wage indexes
are not concentrated within any particular hospital group. Some of the
largest changes are found among both urban and rural hospitals grouped
by census division. In almost all cases, payments change by less than 1
percent. Our review of the wage data (as described below) indicates
that these changes were attributable to improved reporting, as well as
relative changes in labor costs.
In the 50 States and the District of Columbia, among the urban
hospitals, the largest increase (0.6 percent) is in the Middle Atlantic
census division. Significantly, New York City's wage index rises by
over 1.6 percent (this also contributes to the 0.2 percent increase
among major teaching hospitals and the 0.9 percent increase in the
Unknown category under the Medicare Utilization rows). Last year, the
Middle Atlantic experienced one of the largest decreases (0.6 percent),
which contributed to the 0.4 percent decline among major teaching
hospitals--New York City's wage index fell by nearly 2.0 percent in FY
1996 (60 FR 45929). The largest decrease among urban hospitals occurs
in the Pacific census division, with a decline of 0.5 percent.
Among the rural hospitals, the largest increase (0.5 percent) is in
the Pacific census division; the largest decrease (1.0 percent) is in
the New England census division. This decrease is primarily due to a
2.5 percent decrease in the wage index for rural Connecticut hospitals
and a 2.4 percent decrease in the wage index for rural New Hampshire
hospitals. The Pacific rural hospitals also experienced one of the
greatest increases (0.6 percent) among rural hospitals last year.
In Puerto Rico, payments decline by 2.1 percent for the five rural
hospitals and by 0.7 percent for the urban hospitals. The average
hourly wages reported in FY 1993 by two rural Puerto Rico hospitals
fell from those reported in FY 1992 by 22.4 percent and 18.1 percent,
leading to the 2.1 percent overall decline. Of the six urban areas in
Puerto Rico, two experience increases in wage index values while four
experience decreases. Among these four, three experience a decline of
more than 5 percent. These MSAs have relatively few hospitals (two,
five, and seven hospitals). The decreases appear to be the result of
one or two hospitals in each area with a decrease of more than 5
percent in average hourly wages.
The proposed FY 1997 wage index represents the fourth annual update
to the wage data, and will continue to include salaries, fringe
benefits, home office salaries, and certain contract labor costs. In
the past, updates to the wage data have resulted in significant payment
shifts among hospitals. Since the wage index is now updated annually,
we expect these payment fluctuations will decrease.
This expectation is borne out by comparing the proposed FY 1997
wage index (after reclassifications under sections 1886(d)(8)(B) and
1886(d)(10) of the Act) to the FY 1996 wage index. The following chart
compares the shifts in wage index values (after reclassifications) for
labor markets for FY 1997 with those from FY 1996. The majority of
labor market areas (339) experience less than a 5 percent change. Only
25 labor market areas experience a change between 5 and 10 percent; 13
of those experience increases. Still fewer labor markets experience a
change of more than 10 percent; two experience increases and two
experience decreases. For FY 1996, by comparison, 10 labor market areas
experienced an increase in their wage index value of more than 10
percent. We reviewed the data for any area that experienced a wage
index change of 10 percent or more to determine the reason for the
fluctuation.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values -----------------
FY FY
1997 1996
------------------------------------------------------------------------
Increase more than 10 percent......................... 2 10
Increase between 5 and 10 percent, (inclusive)........ 13 21
Increase/decrease below 5 percent..................... 339 331
Decrease between 5 and 10 percent, (inclusive)........ 12 6
Decrease more than 10 percent......................... 2 0
------------------------------------------------------------------------
Under the proposed FY 1997 wage index, 96.2 percent of urban
hospitals and 92.7 percent of rural hospitals would experience a change
in their wage index of less than 5 percent. Approximately 5.9 percent
(3.1 percent of urban hospitals and 2.8 percent of rural hospitals)
would experience a change of between 5 and 10 percent, and 5.3 percent
(0.8 percent of urban hospitals and 4.5 percent of rural hospitals)
would experience a change of more than 10 percent. The following chart
shows the projected impact for urban and rural hospitals.
[[Page 27572]]
------------------------------------------------------------------------
Percent of
hospitals (by
Percentage change in area wage index values Urban/Rural)
-----------------
Urban Rural
------------------------------------------------------------------------
Increase more than 10 percent......................... 0.4 2.5
Increase between 5 and 10 percent (inclusive)......... 1.5 0.9
Increase or decrease less than 5 percent.............. 96.2 2.7
Decrease between 5 and 10 percent (inclusive)......... 1.6 1.9
Decrease more than 10 percent......................... 0.4 2.0
------------------------------------------------------------------------
ANote: The sum of the columns may not total to 100 due to rounding.
D. The Impact of MGCRB Reclassifications (Column 3)
Our impact analysis to this point has assumed hospitals are paid on
the basis of their actual geographic location (with the exception of
ongoing policies that provide that certain hospitals receive payments
on bases other than where they are geographically located, such as RRCs
and hospitals in rural counties that are deemed urban under section
1886(d)(8)(B) of the Act). The changes in column 3 reflect the per case
payment impact of moving from this baseline to a simulation
incorporating the MGCRB decisions for FY 1997. As noted below, these
decisions affect hospitals' standardized amount and wage index area
assignments. In addition, rural hospitals reclassified for purposes of
the standardized amount also qualify to be treated as urban for
purposes of the DSH adjustment.
By March 30 of each year, the MGCRB makes reclassification
determinations that will be effective for the next fiscal year, which
begins on October 1. The MGCRB may reclassify a hospital for the
purpose of using the other area's standardized amount, wage index
value, or both. (RRCs and SCHs are exempt from the proximity
requirement.) Effective FY 1997, rural hospitals can no longer be
reclassified to an other urban area for purposes of the standardized
amount under section 1886(d)(10) of the Act.
The proposed FY 1997 wage index values incorporate all of the
MGCRB's reclassification decisions for FY 1997. The wage index values
also reflect any decisions made by the HCFA Administrator through the
appeals and review process for MGCRB decisions as of March 29, 1996.
Additional changes that result from the Administrator's review of MGCRB
decisions or a request by a hospital to withdraw its application will
be reflected in the final rule for FY 1997.
The overall effect of geographic reclassification is required to be
budget neutral by section 1886(d)(8)(D) of the Act. Therefore, we
applied an adjustment of 0.994059 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4 of the
Addendum to this proposed rule).
As a group, rural hospitals benefit from geographic
reclassification. Their payments rise 2.3 percent, while payments to
urban hospitals decline 0.4 percent. Large urban hospitals lose 0.5
percent because, as a group, they have the smallest percentage of
hospitals that are reclassified (fewer than 3 percent of large urban
hospitals are reclassified). There are enough hospitals in other urban
areas that are reclassified to limit the decrease in payments to urban
hospitals stemming from the budget neutrality offset to 0.2 percent.
Among urban hospital groups generally (that is, bed size, census
division, and special payment status), payments fall between 0.2 and
0.5 percent.
A positive impact is evident among all rural hospital groups except
rural hospitals with up to 49 beds, which experience a 0.0 percent
impact. The smallest effect among all rural census divisions is 0.8
percent for the Middle Atlantic and Mountain divisions. These divisions
have relatively fewer MGCRB reclassifications. Among urban census
divisions, New England displays the smallest negative impact, 0.1
percent.
Among rural hospitals designated as RRCs, 50 hospitals are
reclassified for purposes of the wage index only and experience a 9.5
percent increase in payments overall. This positive impact on RRCs is
also reflected in the category of rural hospitals with 200 or more
beds, which have a 4.9 percent increase in payments.
Rural hospitals reclassified for FY 1996 and FY 1997 experience a
9.1 percent increase in payments, the greatest of any group in the
category. This may be due to the fact that these hospitals have the
most to gain from reclassification and have been reclassified for a
period of years. Rural hospitals reclassified for FY 1997 only
experience a 7.1 percent increase in payments while rural hospitals
reclassified for FY 1996 only experience a 0.4 decrease in payments.
This is due to the budget neutrality adjustment, since the changes in
this column reflect FY 1997 payments relative to no reclassifications,
rather than to FY 1996 reclassifications. Urban hospitals reclassified
for FY 1996 but not FY 1997 experience a 2.0 percent decline in
payments overall. This appears to be due to the combined impacts of the
budget neutrality adjustment and a number of hospitals in this category
that experience a 6 percent drop in their wage index after
reclassification. Urban hospitals reclassified for FY 1997 but not for
FY 1996 experience a 2.4 percent increase in payments.
The FY 1997 Reclassification rows of Table I show the changes in
payments per case for all FY 1997 reclassified and nonreclassified
hospitals in urban and rural locations for each of the three
reclassification categories (standardized amount only, wage index only,
or both). The table illustrates that the largest impact for
reclassified rural hospitals is for those hospitals reclassified for
both the standardized amount and the wage index. These hospitals
receive an 18.8 percent increase in payments. The number of hospitals
in this category has declined from 42 in FY 1996 to 16 in FY 1997. In
addition, rural hospitals reclassified for the wage index receive an
8.8 percent payment increase. The overall impact on reclassified
hospitals is to increase their payments per case by an average of 5.3
percent for FY 1997.
Among the 27 rural hospitals deemed to be urban under section
1886(d)(8)(B) of the Act, payments increase 0.8 percent due to MGCRB
reclassification. This is because, although these hospitals are treated
as being attached to an urban area in our baseline (their redesignation
is ongoing, rather than annual like the MGCRB reclassifications), they
are eligible for MGCRB reclassification. For FY 1997, one hospital in
this category reclassified to a large urban area, resulting in a net
increase due to reclassifications of 0.8 percent.
The reclassification of hospitals primarily affects payment to
nonreclassified hospitals through changes in the wage index and the
geographic reclassification budget neutrality adjustment required by
section 1886(d)(8)(D) of the Act. Among hospitals that are not
reclassified, the overall impact of hospital reclassifications is an
average decrease in payments per case of about 0.6 percent, which
corresponds closely with the geographic reclassification budget
neutrality factor. Rural nonreclassified hospitals decrease slightly
less, experiencing a 0.4 percent decrease. This occurs because the wage
index values in some rural areas increase after reclassified hospitals
are excluded from the calculation of those index values.
The number of reclassifications for purposes of the standardized
amount, or for both the standardized amount and the wage index, has
declined from 358 in FY 1996 to 210 in FY 1997. This is not surprising
because of the elimination of standardized amount
[[Page 27573]]
reclassifications from rural to other urban areas for individual
hospitals. Individual rural hospitals can continue to reclassify to
large urban areas for purposes of the standardized amount. The number
of wage index only reclassifications increased slightly from 260 in FY
1996 to 274 in FY 1997.
The foregoing analysis was based on MGCRB and HCFA Administrator
decisions made by March 29 of this year. As previously noted, there may
be changes to some MGCRB decisions through the appeals, review, and
applicant withdrawal process. The outcome of these cases will be
reflected in the analysis presented in the final rule.
E. Outlier Changes (Column 4)
Medicare provides extra payment in addition to the basic DRG
payment amount for extremely costly or extraordinarily lengthy cases
(cost outliers and day outliers, respectively). Section
1886(d)(5)(A)(v) of the Act requires the Secretary to phase out payment
for day outliers from FY 1994 day outlier levels in 25 percent
increments beginning in FY 1995. Day outliers in FY 1997 should account
for approximately 8 percent of total outlier payments (25 percent of FY
1994 levels). This reduction in day outlier payments will be offset by
an increase in cost outlier payments.
As discussed in the Addendum, for FY 1997, we are proposing a day
outlier threshold equal to the geometric mean length of stay for each
DRG plus the lesser of 24 days or 3.0 standard deviations. The proposed
marginal cost factor for day outliers is 35 percent. For FY 1997, we
are proposing that a case would receive cost outlier payments if its
costs exceed the DRG amount plus $11,050. We are also proposing to
maintain the marginal cost factor for cost outliers at 80 percent.
The payment impacts of these changes are minimal. Hospital
categories negatively affected by phasing out day outliers are
consistent with the categories negatively affected in previous years:
urban New England (0.1 percent decline); urban and rural Middle
Atlantic census divisions (1.1 percent and 0.2 percent declines,
respectively); urban hospitals with 500 or more beds (0.4 percent
decline); teaching hospitals with 100 or more residents (0.5 percent
decline); and hospitals for which data were unavailable to calculate
Medicare utilization rates (1.4 percent decline). As noted in the wage
index discussion previously, this last category contains a number of
New York City hospitals. Because the changes to outlier policy result
in a shift in payments from cases paid as day outliers to cases paid as
cost outliers, this indicates that these categories have higher
percentages of day outliers. The largest positive impact is among urban
hospitals in the West South Central census division (0.4 percent
increase).
F. All Changes (Column 5)
Column 5 compares our estimate of payments per case incorporating
all of our proposed changes for FY 1997 to our estimate of payments per
case in FY 1996. It also includes the effects of the 2.2 percent update
to the standardized amounts and the hospital-specific rates for SCHs
and EACHs, and the 0.9 percentage point difference between the
percentage of projected outlier payments in FY 1997 (5.1 percent) and
the current estimate of the percentage of actual outlier payments in FY
1996 (4.2 percent), as described in the introduction to this Appendix
and the Addendum.
We also note that column 5 includes the impacts of FY 1997 MGCRB
reclassifications compared to the payment impacts of FY 1996
reclassifications. Therefore, when comparing FY 1997 payments to FY
1996, the percent changes due to FY 1997 reclassifications shown in
column 3 need to be offset by the effects of reclassification on
hospitals' FY 1996 payments (column 4 of Table 1, September 1, 1995
final rule; 60 FR 45926). That is, column 3 of Table 1 shows the
impacts of going from no MGCRB reclassifications to the FY 1997
reclassifications. When comparing FY 1996 and FY 1997 payments,
hospitals similarly reclassified during FY 1996 would not experience
the full extent of the change shown in column 3. For example, the
impact of MGCRB reclassifications on rural hospitals' FY 1996 payments
was approximately a 2.3 percent increase, equal to the 2.3 percent
increase for FY 1997. Therefore, the net increase in FY 1997 payments
due to reclassification for rural hospitals is 0 percent.
In addition, eliminating the regional floor provision effective for
discharges occurring on or after October 1, 1996, results in
approximately a 0.2 percent lower average payment in FY 1997 than would
occur otherwise. Of course, this effect is attributable to particular
census divisions, as discussed below.
Finally, the FY 1996 standardized amounts were adjusted by a budget
neutrality factor of 0.997575, in accordance with section 1886(d)(5)(I)
of the Act, so that the change to the transfer payment methodology we
implemented last year (doubling the per diem payment for the first day
of a transfer) would not affect aggregate payments. As we indicated in
last year's final rule (60 FR 45854), this adjustment was applied on a
one-time basis to the FY 1996 standardized amounts. After FY 1996,
there will be no need for a further budget neutrality adjustment unless
or until we make further changes to the transfer payment methodology.
As a result, the FY 1997 standardized amounts are relatively higher
(0.2 percent).
A single geographic reclassification budget neutrality factor of
0.994059 was applied to the proposed FY 1997 standardized amounts,
compared to the FY 1996 factor of 0.994011. The budget neutrality
adjustment factor for the updated wage index and the DRG recalibration
is 0.998509, compared to the FY 1996 factor of 0.999306. Although the
net effect of these changes is small, they are reflected in the payment
differences shown in this column.
There may also be interactive effects among the various factors
comprising the payment system that we are not able to isolate. For
these reasons, the values in column 5 may not equal the sum of the
previous columns plus the other impacts that we are able to identify.
The overall payment increase from FY 1997 to FY 1996 for all
hospitals is a 3.1 percent increase. This reflects the 0.0 percent net
change in total payments due to the proposed changes for FY 1997 shown
in columns 1 through 4, the 2.2 percent update for FY 1997, and the 0.9
percent higher outlier payments in FY 1997 compared to FY 1996, as
discussed above.
Hospitals in urban areas experience a 3.2 percent rise in payments
per case over FY 1996. Similar to all hospitals nationally, this is
primarily due to the factors discussed above: the 2.2 percent update; a
0.9 percent higher level of outlier payments estimated for FY 1997; and
the offsetting effects of eliminating the regional floor and the FY
1996 transfer budget neutrality factor. Urban hospitals benefit 0.1
percent from DRG recalibration, while losing 0.1 percent due to the
phase out of the day outlier policy. Their 0.4 negative impact in FY
1997 due to reclassification is offset by a similar impact from FY 1996
reclassifications.
Hospitals in large and other urban areas experience 3.1 percent and
3.3 percent increases, respectively. The lower increase for hospitals
in large urban areas appears to be attributable primarily to the 0.2
percent negative impact of the continuing phase out of day outliers.
[[Page 27574]]
Hospitals in rural areas experience a 2.7 percent increase. Their
FY 1997 payments are estimated to be 0.6 percent higher than for FY
1996 due to higher outlier payments. Like urban hospitals, the impact
of geographic reclassification in FY 1997 is offset by an identical 2.3
percent increase in FY 1996.
Among urban bed size groups, column 5 shows changes in payments are
higher for the largest urban hospitals compared to smaller urban
hospitals. The relatively smaller increases for the smaller urban
hospitals appear to be due to the negative impacts of the new wage
data, as shown in column 2. Among rural bed size groups, the impacts
range from 2.8 percent to 2.9 percent, with the exception of rural
hospitals with 200 or more beds. Payments per case for this group of
hospitals is estimated to increase 2.2 percent during FY 1997. This
below average rate of increase appears to be attributable primarily to
a smaller, though still significant, impact of MGCRB reclassifications
during FY 1997 compared to FY 1996. In column 3 the FY 1997 impact of
reclassification is shown to be 4.9 percent. For FY 1996, however, this
impact was 5.4 percent. Thus, the rate of increase is 0.5 percent less
for FY 1997 due to a smaller reclassification impact.
As discussed previously, effective for discharges on or after
October 1, 1996, the regional floor, which benefitted certain census
divisions, expires. The regional floor provided that, in those census
divisions where the regional standardized amount exceeded the national
standardized amount, hospitals would be paid a blend of 85 percent of
the national amount and 15 percent of the regional amount. The census
divisions affected by the regional floor during FY 1996 are New England
and East North Central. In New England, the impacts of eliminating the
regional floor are a 0.7 percent decrease for urban hospitals and a 0.6
percent decrease among rural hospitals. In the East North Central
region, the impacts are a 1.0 percent reduction for urban hospitals,
and a 0.7 percent reduction for rural hospitals. The negative impacts
of losing the regional floor for urban hospitals in the East North
Central region are largely offset by higher estimated outlier payments
in FY 1997 compared to FY 1996, the 0.3 percent higher payments due to
the FY 1993 wage data (column 2), and the 0.2 percent increase due to
the phase-out of day outliers (column 4). On the other hand, urban New
England hospitals' higher outlier payments in FY 1997 are offset
entirely by the negative impacts of the expiration of the regional
floor. Rural New England hospitals also see a 1.0 percent decrease in
payments stemming from the FY 1993 wage data.
Other census divisions below the average payment increase are urban
Pacific, urban Puerto Rico, rural Middle Atlantic, rural South
Atlantic, rural East South Central, and rural Mountain. With the
exception of the rural Middle Atlantic and rural East South Central,
the below average overall payment impacts of these census divisions are
related to negative impacts of introducing the FY 1993 wage data. In
the rural Middle Atlantic, the negative impact of the new wage data is
combined with a smaller impact stemming from MGCRB reclassifications in
FY 1997 (0.8 percent compared to 1.5 percent in FY 1996). A smaller FY
1997 reclassification impact (2.5 percent compared with 3.7 percent in
FY 1996) is also the reason for the small (2.2 percent) rate of
increase in the rural East South Central census division.
Conversely, the urban Middle Atlantic, urban West South Central,
rural Pacific, and rural Puerto Rico census divisions all have overall
rates of increase at least 0.4 percent above the national average. The
urban West South Central gains from the continued phase-out of day
outliers, as well as higher estimated FY 1997 outlier payments compared
to FY 1996. As noted previously, the urban Middle Atlantic benefits
significantly from the updated wage index data. These hospitals also
have higher estimated FY 1997 outlier payments, which offset their 1.1
percent decrease due to the phase-out of day outliers. Rural Pacific
hospitals benefit from geographic reclassification in FY 1997, with 12
hospitals being reclassified that were not reclassified in FY 1996.
The only hospital groups with negative payment impacts from FY 1996
to FY 1997 are hospitals that were reclassified for FY 1996 and are not
reclassified for FY 1997. Overall, these hospitals lose 0.5 percent.
The urban hospitals in this category actually experience slight payment
increases over FY 1996 (0.8 percent), while the rural hospitals lose
2.1 percent. On the other hand, hospitals reclassified for FY 1997 that
were not reclassified for FY 1996 would experience the greatest payment
increases: 10.5 percent for 69 rural hospitals in this category and 8.0
percent for 34 urban hospitals.
Reclassification appears to be a significant factor influencing the
payment increases for a number of rural hospital groups with above
average overall payment increases in column 5. For example, among
hospital groups identified in the discussion of the impacts of MGCRB
reclassifications for FY 1997 (column 3), almost all have overall
increases of 3.6 percent or greater. This outcome highlights the
redistributive effects of reclassification decisions upon hospital
payments. This impact is illustrated even more clearly when one
examines the rows categorizing hospitals by their reclassification
status for FY 1997. All nonreclassified hospitals have an average
payment increase of 3.0 percent. The average payment increase for all
reclassified hospitals is 4.3 percent.
Among SCH/EACHs, the payment increase is 2.7 percent. The primary
reason for this below average increase is that there is minimal impact
upon these hospitals from the higher estimated FY 1997 outlier
payments. Because these hospital groups receive their hospital-specific
rate if it exceeds the applicable Federal amount (including outliers),
there is less of an impact due to changes in outlier payment levels,
which are not applied to the hospital-specific rate. In addition,
nonspecial status rural hospitals experience only a 2.1 percent
increase. This is largely attributable to a much smaller
reclassification impact for FY 1997 among these hospitals.
[[Page 27575]]
Table II.--Impact Analysis of Changes for FY 1997 Operating Prospective Payment System
[Payments per case]
Average FY Average FY
Number of 1996 1997
hospitals payment payment All changes
percase percase
(1) (2) \1\ (3) \1\ (4)
----------------------------------------------------------------------------------------------------------------
(By Geographic Location)
----------------------------------------------------------------------------------------------------------------
All hospitals............................................... 5,130 6,470 6,673 3.1
Urban hospitals............................................. 2,878 7,004 7,229 3.2
Large urban areas........................................... 1,597 7,524 7,761 3.1
Other urban areas........................................... 1,281 6,317 6,524 3.3
Rural areas................................................. 2,252 4,302 4,419 2.7
Bed size (urban):
0-99 beds............................................... 716 4,721 4,862 3.0
100-199 beds............................................ 938 5,939 6,112 2.9
200-299 beds............................................ 577 6,521 6,722 3.1
300-499 beds............................................ 479 7,410 7,660 3.4
500 or more beds........................................ 168 9,150 9,457 3.4
Bed Size (rural):
0-49 beds............................................... 1,173 3,540 3,639 2.8
50-99 beds.............................................. 663 3,996 4,108 2.8
100-149 beds............................................ 241 4,462 4,593 2.9
150-199 beds............................................ 99 4,582 4,713 2.8
200 or more beds........................................ 76 5,417 5,537 2.2
Urban by Census div.:
New England............................................. 160 7,508 7,686 2.4
Middle Atlantic......................................... 434 7,686 7,953 3.5
South Atlantic.......................................... 419 6,664 6,887 3.3
East North Central...................................... 483 6,742 6,940 2.9
East South Central...................................... 163 6,185 6,395 3.4
West North Central...................................... 193 6,652 6,880 3.4
West South Central...................................... 375 6,524 6,756 3.6
Mountain................................................ 125 6,774 6,996 3.3
Pacific................................................. 478 8,077 8,313 2.9
Puerto Rico............................................. 48 2,584 2,652 2.6
Rural by Census div.:
New England............................................. 53 5,236 5,344 2.1
Middle Atlantic......................................... 85 4,695 4,785 1.9
South Atlantic.......................................... 297 4,476 4,591 2.6
East North Central...................................... 304 4,328 4,454 2.9
East South Central...................................... 278 3,960 4,048 2.2
West North Central...................................... 525 4,008 4,121 2.8
West South Central...................................... 351 3,876 4,001 3.2
Mountain................................................ 213 4,575 4,712 3.0
Pacific................................................. 141 5,306 5,519 4.0
Puerto Rico............................................. 5 2,042 2,118 3.8
----------------------------------------------------------------------------------------------------------------
(By Payment Categories)
----------------------------------------------------------------------------------------------------------------
Urban hospitals............................................. 2,978 6,960 7,184 3.2
Large urban areas........................................... 1,793 7,352 7,586 3.2
Other urban areas........................................... 1,185 6,322 6,528 3.3
Rural areas................................................. 2,152 4,269 4,379 2.6
Teaching status:
Non-teaching............................................ 4,057 5,293 5,458 3.1
Fewer than 100 residents................................ 841 6,900 7,118 3.2
100 or more residents................................... 232 10,565 10,901 3.2
Disproportionate Share Hospitals (DSH):
Non-DSH................................................. 3,200 5,602 5,779 3.2
Urban DSH:
100 beds or more.................................... 1,410 7,595 7,835 3.2
Fewer than 100 beds................................. 111 4,811 4,929 2.5
Rural DSH:
Sole community (SCH)................................ 146 4,478 4,625 3.3
Referral centers (RRC).............................. 25 5,216 5,409 3.7
Other rural DSH hosp.:
100 beds or more.................................... 89 4,235 4,280 1.1
Fewer than 100 beds................................. 149 3,412 3,497 2.5
Urban Teaching and DSH:
Both teaching and DSH................................... 682 8,576 8,843 3.1
Teaching and no DSH..................................... 337 7,094 7,324 3.2
[[Page 27576]]
No Teaching and DSH..................................... 839 6,093 6,292 3.3
No teaching and no DSH.................................. 1,120 5,479 5,663 3.4
Rural hospital types:
Nonspecial Status Hospitals............................. 1,382 3,901 3,984 2.1
RRC..................................................... 90 5,068 5,249 3.6
SCH/Each................................................ 641 4,415 4,536 2.7
SCH/Each and RRC........................................ 39 5,200 5,345 2.8
Type of ownership:
Voluntary............................................... 3,084 6,634 6,846 3.2
Proprietary............................................. 691 5,917 6,093 3.0
Government.............................................. 1,355 6,030 6,207 2.9
Medicare utilization as a percent of inpatient days
0-25.................................................... 256 8,577 8,803 2.6
25-50................................................... 1,285 7,877 8,124 3.1
50-65................................................... 2,105 5,944 6,133 3.2
Over 65................................................. 1,353 5,062 5,220 3.1
Unknown................................................. 131 7,372 7,597 3.1
----------------------------------------------------------------------------------------------------------------
Hospitals Reclassified by the Medicare Geographic Review Board
----------------------------------------------------------------------------------------------------------------
Reclassification status during FY96 and FY97:
Reclassified during both FY96 and FY97.................. 381 5,864 6,046 3.1
Urban............................................... 133 6,750 6,976 3.4
Rural............................................... 248 5,003 5,143 2.8
Reclassified during FY97 only........................... 103 6,150 6,679 8.6
Urban............................................... 34 7,091 7,658 8.0
Rural............................................... 69 4,374 4,831 10.5
Reclassified during FY96 only........................... 251 5,658 5,630 -0.5
Urban............................................... 88 7,131 7,189 0.8
Rural............................................... 163 4,515 4,421 -2.1
FY 97 Reclassifications: All reclassified hosp. 484 5,922 6,176 4.3
Stand. amt. Only.................................... 120 5,764 5,944 3.1
Wage index only..................................... 274 5,839 6,065 3.9
Both................................................ 90 6,205 6,571 5.9
Nonreclass.......................................... 4,619 6,548 6,745 3.0
All urban reclass....................................... 167 6,837 7,150 4.6
Stand. amt. only.................................... 63 6,230 6,433 3.3
Wage index only..................................... 30 9,311 9,728 4.5
Both................................................ 74 6,370 6,727 5.6
Nonreclass.......................................... 2,711 7,018 7,235 3.1
All rural reclass....................................... 317 4,909 5,096 3.8
Stand. amt. only.................................... 57 4,623 4,749 2.7
Wage index only..................................... 244 4,968 5,146 3.6
Both................................................ 16 4,898 5,345 9.1
Nonreclass.......................................... 1,908 4,063 4,152 2.2
Other reclassifed:
Hospitals (section 1886(d)(8)(B))....................... 27 4,611 4,756 3.1
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increases.
Table II presents the projected impact of the proposed changes for
FY 1997 for urban and rural hospitals and for the different categories
of hospitals shown in Table I. It compares the projected payments per
case for FY 1997 with the average estimated per case payments for FY
1996, as calculated under our models. Thus, this table presents, in
terms of the average dollar amounts paid per discharge, the combined
effects of the changes presented in Table I. The percentage changes
shown in the last column of Table I equal the percentage changes in
average payments from column 5 of Table I.
VII. Impact of Proposed Changes in the Capital Prospective Payment
System
A. General Considerations
We now have data that were unavailable in previous impact analyses
for the capital prospective payment system. Specifically, we have cost
report data for the third year of the capital prospective payment
system (cost reports beginning in FY 1994) available through the March
1996 update of the Hospital Cost Report Information System (HCRIS). We
also have updated information on the projected aggregate amount of
obligated capital approved by the fiscal intermediaries. However, our
impact analysis of payment changes for capital-related costs is still
limited by the lack of hospital-specific data on several items. These
are the hospital's projected new capital costs for each year, its
projected old capital costs for
[[Page 27577]]
each year, and the actual amounts of obligated capital that will be put
in use for patient care and recognized as Medicare old capital costs in
each year. The lack of such information affects our impact analysis in
the following ways:
Major investment in hospital capital assets (for example
in building and major fixed equipment) occurs at irregular intervals.
As a result, there can be significant variation in the growth rates of
Medicare capital-related costs per case among hospitals. We do not have
the necessary hospital-specific budget data to project the hospital
capital growth rate for individual hospitals.
Moreover, our policy of recognizing certain obligated
capital as old capital makes it difficult to project future capital-
related costs for individual hospitals. Under Sec. 412.302(c), a
hospital is required to notify its intermediary that it has obligated
capital by the later of October 1, 1992, or 90 days after the beginning
of the hospital's first cost reporting period under the capital
prospective payment system. The intermediary must then notify the
hospital of its determination whether the criteria for recognition of
obligated capital have been met by the later of the end of the
hospital's first cost reporting period subject to the capital
prospective payment system or 9 months after the receipt of the
hospital's notification. The amount that is recognized as old capital
is limited to the lesser of the actual allowable costs when the asset
is put in use for patient care or the estimated costs of the capital
expenditure at the time it was obligated. We have substantial
information regarding intermediary determinations of projected
aggregate obligated capital amounts. However, we still do not know when
these projects will actually be put into use for patient care, the
actual amount that will be recognized as obligated capital when the
project is put into use, or the Medicare share of the recognized costs.
Therefore, we do not know actual obligated capital commitments for
purposes of the FY 1997 capital cost projections. We discuss in
Appendix B the assumptions and computations we employ to generate the
amount of obligated capital commitments for use in the FY 1997 capital
cost projections.
In Table III of this appendix, we present the redistributive
effects that are expected to occur between ``hold-harmless'' hospitals
and ''fully prospective'' hospitals in FY 1997. In addition, we have
integrated sufficient hospital-specific information into our actuarial
model to project the impact of the proposed FY 1997 capital payment
policies by the standard prospective payment system hospital groupings.
We caution that while we now have actual information on the effects of
the transition payment methodology and interim payments under the
capital prospective payment system and cost report data for most
hospitals, we need to randomly generate numbers for the change in old
capital costs, new capital costs for each year, and obligated amounts
that will be put in use for patient care services and recognized as old
capital each year. We continue to be unable to predict accurately FY
1997 capital costs for individual hospitals, but with the more recent
data on the experience to date under the capital prospective payment
system, there is adequate information to estimate the aggregate impact
on most hospital groupings.
We present the transition payment methodology by hospital grouping
in Table IV. In Table V we present the results of the cross-sectional
analysis using the results of our actuarial model. This table presents
the aggregate impact of the FY 1997 payment policies.
B. Projected Impact Based on the Proposed FY 1997Actuarial Model
1. Assumptions
In this impact analysis, we model dynamically the impact of the
capital prospective payment system from FY 1996 to FY 1997 using a
capital acquisition model. The FY 1997 model, described in Appendix B
of this proposed rule, integrates actual data from individual hospitals
with randomly generated capital cost amounts. We have capital cost data
from cost reports beginning in FY 1989 through FY 1994 received through
the March 1996 update of the Hospital Cost Reporting Information System
(HCRIS), interim payment data for hospitals already receiving capital
prospective payments through PRICER, and data reported by the
intermediaries that include the hospital-specific rate determinations
that have been made through January 1, 1996 in the Provider-Specific
file. We used this data to determine the proposed FY 1997 capital
rates. However, we do not have individual hospital data on old capital
changes, new capital formation, and actual obligated capital costs. We
have data on costs for capital in use in FY 1993, and we age that
capital by a formula described in Appendix B. We therefore need to
randomly generate only new capital acquisitions for any year after FY
1993. All Federal rate payment parameters are assigned to the
applicable hospital.
For purposes of this impact analysis, the FY 1997 actuarial model
includes the following assumptions:
Medicare inpatient capital costs per discharge will
increase at the following rates during these periods:
Average Percentage Increase in Capital
------------------------------------------------------------------------
Costs per
Fiscal year discharge
------------------------------------------------------------------------
1995....................................................... -1.50
1996....................................................... 5.05
1997....................................................... 5.21
------------------------------------------------------------------------
The Medicare case-mix index will increase by 1.6 percent
in FY 1996 and FY 1997.
The Federal capital rate as well as the hospital-specific
rate is updated in FY 1996 by an analytical framework that considers
changes in the prices associated with capital-related costs, and
adjustments to account for forecast error, changes in the case-mix
index, allowable changes in intensity, and other factors. The proposed
FY 1997 update for inflation is 1.00 percent (see Addendum, Part III).
2. Results
We have used the actuarial model to estimate the change in payment
for capital-related costs from FY 1996 to FY 1997. Table III shows the
effect of the capital prospective payment system on low capital cost
hospitals and high capital cost hospitals. We consider a hospital to be
a low capital cost hospital if, based on a comparison of its initial
hospital-specific rate and the applicable Federal rate, it will be paid
under the fully prospective payment methodology. A high capital cost
hospital is a hospital that, based on its initial hospital-specific
rate, will be paid under the hold-harmless payment methodology. Based
on our actuarial model, the breakdown of hospitals is as follows:
[[Page 27578]]
Capital Transition Payment Methodology
----------------------------------------------------------------------------------------------------------------
FY 1997 FY 1997
Percent of FY 1997 percent of percent of
Type of hospital hospitals percent of capital capital
discharges costs payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital........................................... 66 62 53 56
High Cost Hospital.......................................... 34 38 47 44
----------------------------------------------------------------------------------------------------------------
A low capital cost hospital may request to have its hospital-
specific rate redetermined based on old capital costs in the current
year, through the later of the hospital's cost reporting period
beginning in FY 1994 or the first cost reporting period beginning after
obligated capital comes into use (within the limits established in
Sec. 412.302(e) for putting obligated capital in use for patient care).
If the redetermined hospital-specific rate is greater than the adjusted
Federal rate, these hospitals will be paid under the hold-harmless
payment methodology. Regardless of whether the hospital became a hold-
harmless payment hospital as a result of a redetermination, we have
continued to show these hospitals as low capital cost hospitals in
Table III.
Assuming no behavioral changes in capital expenditures, Table III
displays the percentage change in payments from FY 1996 to FY 1997
using the above described actuarial model.
[[Page 27579]]
Table III.--Impact of Proposed Changes for FY 1997 on Payments per Discharge
FY 1996 payments per discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Average Hospital Hold
Number of Discharges federal federal specific harmless Exceptions Total
hospitals payment percent payment payment payment payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
Low Cost Hospitals...................................... 3,367 6,543,036 $413.51 55.01 $200.60 $15.30 $16.59 $646.01
Fully Prospective................................... 1,472 2,953,665 373.96 50.00 236.94 .......... 11.59 622.49
Rebase--Fully Prospective........................... 1,561 2,777,809 373.98 50.00 220.57 .......... 23.17 617.72
Rebase--100% Federal Rate........................... 237 633,924 798.96 100.00 .......... .......... 0.05 799.00
Rebase--Hold Harmless............................... 97 177,638 313.93 44.64 .......... 563.62 55.92 933.48
High Cost Hospitals..................................... 1,737 4,044,123 665.47 85.61 .......... 152.51 16.36 834.35
100% Federal Rate................................... 1,126 2,842,423 788.87 100.00 .......... .......... 2.30 791.18
Hold Harmless....................................... 611 1,201,700 373.59 49.81 .......... 513.26 49.61 936.46
Total Hospitals................................... 5,104 10,587,159 509.76 66.94 123.98 67.71 16.50 717.95
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 1997 payments per discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Average Hospital Hold
Number of Discharges federal federal specific harmless Exceptions Total Percent
hospitals payment percent payment payment payment payment change
--------------------------------------------------------------------------------------------------------------------------------------------------------
Low Cost Hospitals.......................... 3,367 6,720,494 $472.14 64.07 $157.08 $12.37 $38.44 $680.03 5.27
Fully Prospective....................... 1,472 3,033,773 438.87 60.00 185.55 .......... 34.06 658.48 5.78
Rebase--Fully Prospective............... 1,561 2,853,148 440.66 60.00 172.70 .......... 45.15 658.50 6.60
Rebase--100% Federal Rate............... 243 657,828 785.22 100.00 .......... .......... 0.58 785.81 -1.65
Rebase--Hold Harmless................... 91 175,744 385.79 55.77 .......... 473.19 146.68 1,005.66 7.73
High Cost Hospitals......................... 1,737 4,153,806 691.63 89.42 .......... 123.03 48.28 862.93 3.43
100% Federal Rate....................... 1,164 2,988,949 780.85 100.00 .......... .......... 11.02 791.87 0.09
Hold Harmless........................... 573 1,164,856 462.69 61.34 .......... 438.70 143.88 1,045.27 11.62
Total Hospitals....................... 5,104 10,874,300 555.98 74.04 97.08 54.64 42.20 749.90 4.45
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 27580]]
Under section 1886(g)(1)(A) of the Act, aggregate payments under
the capital prospective payment system for FY 1992 through 1995
respectively, were projected to equal 90 percent of payments that would
have been payable on a reasonable cost basis in each year. With the
expiration of the capital budget neutrality provision, we now estimate
that there was an aggregate 27.73 percent increase in FY 1996 Medicare
capital payments over the FY 1995 payments. With the proposed Federal
rate, we estimate aggregate Medicare capital payments will increase by
7.28 percent in FY 1997.
We project that low capital cost hospitals paid under the fully
prospective payment methodology will experience an average increase in
payments per case of 5.27 percent, and high capital cost hospitals will
experience an average increase of 3.43 percent.
For hospitals paid under the fully prospective payment methodology,
the Federal rate payment percentage will increase from 50 percent to 60
percent and the hospital-specific rate payment percentage will decrease
from 50 to 40 percent in FY 1997. The Federal rate payment percentage
for hospitals paid under the hold-harmless payment methodology is based
on the hospital's ratio of new capital costs to total capital costs.
The average Federal rate payment percentage for hospitals receiving a
hold-harmless payment for old capital will increase from 49.81 percent
to 61.34 percent. We estimate the percentage of hold-harmless hospitals
paid based on 100 percent of the Federal rate will increase from 65.8
percent to 67.9 percent.
We expect that the average hospital-specific rate payment per
discharge will decrease from $123.98 in FY 1996 to $97.08 in FY 1997.
This is partly due to the 3.68 percent decrease in the FY 1997
hospital-specific rate compared to FY 1996.
We are proposing no changes in our exceptions policies for FY 1997.
As a result, the minimum payment levels would be:
90 percent for sole community hospitals;
80 percent for urban hospitals with 100 or more beds and a
disproportionate share patient percentage of 20.2 percent or more; or,
70 percent for all other hospitals.
We estimate that exceptions payments will increase from 2.30
percent of total capital payments in FY 1996 to 5.63 percent of
payments in FY 1997. The number and amount of exceptions payments is
expected to increase throughout the transition period. The projected
distribution of the payments is shown in the table below:
Estimated FY 1997 Exceptions Payments
------------------------------------------------------------------------
Percent of
Type of hospital Number of exceptions
hospitals payments
------------------------------------------------------------------------
Low Capital Cost.............................. 450 58
High Capital Cost............................. 331 42
-------------------------
Total..................................... 781 100
------------------------------------------------------------------------
C. Cross-Sectional Comparison of Capital Prospective Payment
Methodologies
Table IV presents a cross-sectional summary of hospital groupings
by capital prospective payment methodology. This distribution is
generated by our actuarial model.
Table IV.--Distribution by Method of Payment (Hold-Harmless/Fully Prospective) of Hospitals Receiving Capital
Payments
----------------------------------------------------------------------------------------------------------------
(2) Hold-harmless
-------------------------- (3)
(1) Total Percentage Percentage
Number of paid hold- Percentage paid fully
Hospitals harmless paid fully prospective
(A) federal (B) rate
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals........................................... 5,104 13.0 27.6 59.4
Large urban areas (populations over 1 million).......... 1,584 15.6 34.5 49.9
Other urban areas (populations of 1 million or fewer)... 1,271 15.1 33.4 51.5
Rural areas............................................. 2,249 10.0 19.4 70.6
Urban hospitals......................................... 2,855 15.4 34.0 50.6
0-99 beds........................................... 698 16.2 27.7 56.2
100-199 beds........................................ 933 19.3 36.8 43.9
200-299 beds........................................ 577 13.9 37.3 48.9
300-499 beds........................................ 479 11.5 32.6 55.9
500 or more beds.................................... 168 6.5 37.5 56.0
Rural hospitals......................................... 2,249 10.0 19.4 70.6
0-49 beds........................................... 1,171 7.1 14.3 78.7
50-99 beds.......................................... 662 12.8 21.9 65.3
100-149 beds........................................ 241 14.5 30.3 55.2
150-199 beds........................................ 99 16.2 22.2 61.6
200 or more beds.................................... 76 7.9 39.5 52.6
By Region:
Urban by Region......................................... 2,855 15.4 34.0 50.6
New England......................................... 160 7.5 25.0 67.5
Middle Atlantic..................................... 434 9.9 30.0 60.1
South Atlantic...................................... 417 19.2 41.0 39.8
East North Central.................................. 480 11.3 28.5 60.2
East South Central.................................. 162 19.8 36.4 43.8
West North Central.................................. 190 17.4 28.4 54.2
West South Central.................................. 366 25.7 47.5 26.8
Mountain............................................ 124 15.3 42.7 41.9
Pacific............................................. 474 13.3 30.4 56.3
Puerto Rico......................................... 48 18.8 16.7 64.6
Rural by Region......................................... 2,249 10.0 19.4 70.6
[[Page 27581]]
New England......................................... 53 7.5 15.1 77.4
Middle Atlantic..................................... 84 6.0 19.0 75.0
South Atlantic...................................... 297 13.1 25.3 61.6
East North Central.................................. 304 8.6 13.5 78.0
East South Central.................................. 278 10.1 30.6 59.4
West North Central.................................. 525 7.2 15.0 77.7
West South Central.................................. 349 10.0 24.1 65.9
Mountain............................................ 213 15.5 12.7 71.8
Pacific............................................. 141 11.3 15.6 73.0
Large urban areas (populations over 1 million).......... 1,780 15.3 34.3 50.4
Other urban areas (populations of 1 million or fewer)... 1,175 15.4 32.3 52.3
Rural areas............................................. 2,149 9.8 19.4 70.8
Teaching Status:
Non-teaching........................................ 4,031 13.7 26.6 59.7
Fewer than 100 Residents............................ 841 11.1 32.0 57.0
100 or more Residents............................... 232 7.8 28.4 63.8
Disproportionate share hospitals (DSH):
Non-DSH............................................. 3,175 12.7 23.8 63.5
Urban DSH:
100 or more beds................................ 1,410 15.0 36.2 48.8
Less than 100 beds.............................. 110 11.8 25.5 62.7
Rural DSH:
Sole Community (SCH/EACH)........................... 146 9.6 20.5 69.9
Referral Center (RRC/EACH).......................... 25 8.0 32.0 60.0
Other Rural:
100 or more beds............................ 89 13.5 39.3 47.2
Less than 100 beds.......................... 149 6.7 25.5 67.8
Urban teaching and DSH:
Both teaching and DSH............................... 682 9.1 32.8 58.1
Teaching and no DSH................................. 337 13.6 27.6 58.8
No teaching and DSH................................. 838 19.3 37.6 43.1
No teaching and no DSH.............................. 1,098 16.7 32.7 50.6
Rural Hospital Types:
NON special status hospitals........................ 1,379 7.6 19.5 72.9
RRC/EACH............................................ 90 8.9 37.8 53.3
SCH/EACH............................................ 641 14.5 16.4 69.1
SCH, RRC and EACH................................... 39 12.8 20.5 66.7
Type of Ownership:
Voluntary:
Voluntary........................................... 3,058 12.8 27.7 59.5
Proprietary......................................... 691 23.6 46.2 30.2
Government.......................................... 1,355 8.1 17.9 74.0
Medicare Utilization as a Percent of Inpatient Days:
0-25................................................ 256 14.8 25.0 60.2
25-50............................................... 1,285 14.6 33.1 52.3
50-65............................................... 2,105 12.9 27.8 59.3
Over 65............................................. 1,353 10.4 22.2 67.3
----------------------------------------------------------------------------------------------------------------
As we explain in Appendix B, we were not able to determine a
hospital-specific rate for 26 of the 5,130 hospitals in our data base.
Consequently, the payment methodology distribution is based on 5,104
hospitals. This data should be fully representative of the payment
methodologies that will be applicable to hospitals.
The cross-sectional distribution of hospital by payment methodology
is presented by: (1) geographic location, (2) region, and (3) payment
classification. This provides an indication of the percentage of
hospitals within a particular hospital grouping that will be paid under
the fully prospective payment methodology and under the hold-harmless
methodology.
The percentage of hospitals paid fully Federal (100 percent of the
Federal rate) as hold-harmless hospitals is expected to increase to
27.6 percent in FY 1997.
Table IV indicates that 59.4 percent of hospitals are paid under
the fully prospective payment methodology. (This figure, unlike the
figure of 66 percent for low cost capital hospitals in the previous
section, takes account of the effects of redeterminations. In other
words, this figure does not include low cost hospitals that, following
a hospital-specific rate redetermination, are now paid under the hold-
harmless methodology.) As expected, a relatively higher percentage of
rural and governmental hospitals (70.8 percent and 74.0 percent,
respectively by payment classification) are being paid under the fully
prospective methodology. This is a reflection of their lower than
average capital costs
[[Page 27582]]
per case. In contrast, only 30.2 percent of proprietary hospitals are
being paid under the fully prospective methodology. This is a
reflection of their higher than average capital costs per case. (We
found at the time of the August 30, 1991 final rule (56 FR 43430) that
62.7 percent of proprietary hospitals had a capital cost per case above
the national average cost per case.)
D. Cross-Sectional Analysis of Changes in Aggregate Payments
We used our FY 1997 actuarial model to estimate the potential
impact of our proposed changes for FY 1997 on total capital payments
per case, using a universe of 5,104 hospitals. The individual hospital
payment parameters are taken from the best available data, including:
the January 1, 1996 update to the Provider-Specific file, cost report
data, and audit information supplied by intermediaries. Table V
presents estimates of payments per case under our model for FY 1996 and
FY 1997 (columns 2 and 3). Column 4 shows the total percentage change
in payments from FY 1996 to FY 1997. Column 5 presents the percentage
change in payments that can be attributed to Federal rate changes
alone.
Federal rate changes represented in Column 5 include the 4.36
percent decrease in the Federal rate, a 1.6 percent increase in case
mix, changes in the adjustments to the Federal rate (for example, the
effect of the new hospital wage index on the geographic adjustment
factor), and reclassifications by the Medicare Geographic
Classification Review Board. Column 4 includes the effects of the
Federal rate changes represented in Column 3. Column 4 also reflects
the effects of all other changes, including: the change from 50 percent
to 60 percent in the portion of the Federal rate for fully prospective
hospitals, the hospital-specific rate update, changes in the proportion
of new to total capital for hold-harmless hospitals, changes in old
capital (for example, obligated capital put in use), hospital-specific
rate redeterminations, and exceptions. The comparisons are provided by:
(1) geographic location and (2) payment classification and payment
region.
The simulation results show that, on average, capital payments per
case can be expected to increase 4.4 percent in FY 1997. The results
show that the effect of the Federal rate changes alone is to decrease
payments by 0.9 percent. The decrease attributable to the Federal rate
changes is more than offset by a 5.3 percent increase is attributable
to the effects of all other changes.
Our comparison by geographic location shows that capital payments
per case to urban and rural hospitals experience similar rates of
increase (4.4 percent and 4.8 percent, respectively). Payments per case
for urban hospitals will decrease at about the same rate as payments
per case for rural hospitals (0.8 percent and 1.3 percent,
respectively) from the Federal rate changes alone. Urban hospitals will
gain slightly less than rural hospitals (5.2 percent compared to 6.1
percent) from the effects of all other changes.
By region, there is relatively little variation compared to some
previous years. All regions are estimated to receive increases in total
capital payments per case, due to the increased share of payments that
is based on the Federal rate (from 50 to 60 percent). Changes by region
vary from a low of 2.1 percent increase (Middle Atlantic rural region)
to a high of 15.6 percent increase (rural hospitals of the New England
region).
By type of ownership, government hospitals are projected to have
the largest rate of increase (5.1 percent, -1.1 percent due to Federal
rate changes and a 6.2 percent positive offset from the effects of all
other changes). Payments to voluntary hospitals will increase 4.5
percent (a 0.9 percent decrease due to Federal rate changes and a 5.4
percent positive offset from the effects of all other changes) and
payments to proprietary hospitals will increase 3.8 percent (a 0.7
percent decrease due to Federal rate changes and a 4.5 percent positive
offset from the effects of all other changes).
Section 1886(d)(10) of the Act established the Medicare Geographic
Classification Review Board (MGCRB). Hospitals may apply for
reclassification for purposes of the standardized amount, wage index,
or both. Although the Federal capital rate is not affected, a
hospital's geographic classification for purposes of the operating
standardized amount does affect a hospital's capital payments as a
result of the large urban adjustment factor and the disproportionate
share adjustment for urban hospitals with 100 or more beds.
Reclassification for wage index purposes affects the geographic
adjustment factor since that factor is constructed from the hospital
wage index.
To present the effects of the hospitals being reclassified for FY
1997 compared to the effects of reclassification for FY 1996, we show
the average payment percentage increase for hospitals reclassified in
each fiscal year and in total. For FY 1997 reclassifications, we
indicate those hospitals reclassified for standardized amount purposes
only, for wage index purposes only, and for both purposes. The
reclassified groups are compared to all other nonreclassified
hospitals. These categories are further identified by urban and rural
designation.
Hospitals reclassified during FY 1997 as a whole are projected to
experience a 5.3 percent increase in payments (a 0.3 percent decrease
attributable to Federal rate changes and a 5.6 percent positive offset
attributable to the effects of all other changes). Payments to
nonreclassified hospitals will increase slightly less (4.3 percent)
than reclassified hospitals (5.3 percent) overall. Payments to
nonreclassified hospitals will decrease slightly more than reclassified
hospitals from the Federal rate changes (1.0 percent compared to 0.3
percent), but they will gain about the same from the effects of all
other changes (5.3 percent compared to 5.6 percent).
Table V.--Comparison of Total Payments Per Case
[FY 1996 Payments Compared to FY 1997 Payments]
----------------------------------------------------------------------------------------------------------------
Portion
Number of Average FY Average FY attibutable
hospitals 1996 pay- 1997 pay- All changes to federal
ments/case ments/case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals.............................. 5,104 718 750 4.4 -0.9
Large urban areas (populations over 1
million).................................. 1,584 823 858 4.3 -0.9
Other urban areas (populations of 1 million
of fewer)................................. 1,271 714 747 4.5 -0.8
Rural areas................................ 2,249 479 503 4.8 -1.3
Urban hospitals............................ 2,855 776 810 4.4 -0.8
[[Page 27583]]
0-99 beds.............................. 698 570 594 4.3 -0.9
100-199 beds........................... 933 703 731 4.1 -1.0
200-299 beds........................... 577 744 776 4.2 -0.9
300-499 beds........................... 479 800 838 4.8 -0.8
500 or more beds....................... 168 944 984 4.3 -0.5
Rural hospitals............................ 2,249 479 503 4.8 -1.3
0-49 beds.............................. 1,171 368 389 5.8 -1.5
50-99 beds............................. 662 445 468 5.0 -1.2
100-149 beds........................... 241 512 536 4.7 -1.3
150-199 beds........................... 99 517 543 4.9 -1.0
200 or more beds....................... 76 609 633 3.9 -1.5
By Region:
Urban by Region............................ 2,855 776 810 4.4 -0.8
New England............................ 160 780 818 4.9 -1.5
Middle Atlantic........................ 434 816 855 4.8 -0.8
South Atlantic......................... 417 777 809 4.2 -0.8
East North Central..................... 480 730 759 4.0 -0.7
East South Central..................... 162 707 744 5.3 -0.5
West North Central..................... 190 768 807 5.1 -0.8
West South Central..................... 366 794 825 3.8 -0.3
Mountain............................... 124 774 804 3.8 -1.1
Pacific................................ 474 856 890 4.1 -1.3
Puerto Rico............................ 48 291 313 7.5 -1.1
Rural by Region............................ 2,249 479 503 4.8 -1.3
New England............................ 53 605 699 15.6 -1.8
Middle Atlantic........................ 84 489 499 2.1 -2.4
South Atlantic......................... 297 501 518 3.4 -1.5
East North Central..................... 304 479 506 5.7 -0.9
East South Central..................... 278 453 471 4.0 -1.5
West North Central..................... 525 449 471 5.0 -1.4
West South Central..................... 349 447 467 4.4 -0.9
Mountain............................... 213 507 540 6.4 -0.5
Pacific................................ 141 549 582 6.1 -0.9
By Payment Classification:
All hospitals.............................. 5,104 718 750 4.4 -0.9
Large urban areas (populations over 1
million).................................. 1,780 808 842 4.3 -0.9
Other urban areas (populations of 1 million
of fewer)................................. 1,175 714 747 4.6 -0.8
Rural areas................................ 2,149 473 495 4.8 -1.4
Teaching Status:
Non-teaching........................... 4,031 623 647 3.9 -1.0
Fewer than 100 Residents............... 841 756 791 4.7 -0.9
100 or more Residents.................. 232 1,039 1,096 5.5 -0.7
Urban DSH:
100 or more beds................... 1,410 814 850 4.5 -0.9
Less than 100 beds................. 110 557 587 5.4 -1.1
Rural DSH:
Sole Community (SCH/EACH).......... 146 458 495 8.1 -1.9
Referral Center (RRC/EACH)......... 25 544 560 2.9 -0.2
Other Rural:
100 or more beds................... 89 501 519 3.6 -1.9
Less than 100 beds................. 149 365 385 5.5 -1.6
Urban teaching and DSH:....................
Both teaching and DSH.................. 682 879 919 4.6 -0.8
Teaching and no DSH.................... 337 786 827 5.3 -0.8
No teaching and DSH.................... 838 712 743 4.4 -0.9
No teaching and no DSH................. 1,098 672 695 3.4 -0.8
Rural Hospital Types:
Non special status hospitals........... 1,379 439 458 4.3 -1.7
RRC/EACH............................... 90 559 574 2.5 -0.8
SCH/EACH............................... 641 471 506 7.4 -1.2
SCH, RRC and EACH...................... 39 577 608 5.4 -1.0
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY96
and FY97:
Reclassified During Both FY96 and
FY97.............................. 381 668 698 4.5 -1.1
Reclassified During FY97 Only...... 103 678 736 8.6 2.9
Reclassified During FY96 Only...... 228 631 640 1.4 -3.6
FY97 Reclassifications:
All Reclassified Hospitals......... 484 670 706 5.3 -0.3
[[Page 27584]]
All Nonreclassified Hospitals...... 4,593 725 756 4.3 -1.0
All Urban Reclassified Hospitals... 167 762 799 4.9 -0.3
Urban Nonreclassified Hospitals.... 2,688 777 811 4.3 -0.9
All Reclassified Rural Hospitals... 317 568 602 6.0 -0.3
Rural Nonreclassified Hospitals.... 1,905 443 463 4.3 -1.8
Other Reclassified Hospitals (Section
1886 (D)(8)(B))....................... 27 552 575 4.1 -1.3
Type of Ownership:
Voluntary.............................. 3,058 732 765 4.5 -0.9
Proprietary............................ 691 748 776 3.8 -0.7
Government............................. 1,355 618 649 5.1 -1.1
Medicare Utilization as a Percent of
Inpatient Days:
0-25................................... 256 793 847 6.8 -1.4
25-50.................................. 1,285 844 880 4.2 -0.8
50-65.................................. 2,105 675 706 4.6 -0.9
Over 65................................ 1,353 603 628 4.1 -1.0
----------------------------------------------------------------------------------------------------------------
Appendix B: Technical Appendix on the Capital Acquisition Model and
Required Adjustments
Under section 1886(g)(1)(A) of the Act, we set capital prospective
payment rates for FY 1992 through FY 1995 so that aggregate prospective
payments for capital costs were projected to be 10 percent lower than
the amount that would have been payable on a reasonable cost basis for
capital-related costs in that year. To implement this requirement, we
developed the capital acquisition model to determine the budget
neutrality adjustment factor. Even though the budget neutrality
requirement expires effective with FY 1996, we must continue to
determine the recalibration and geographic reclassification budget
neutrality adjustment factor, and the reduction in the Federal and
hospital-specific rates for exceptions payments. We continue to use the
capital acquisition model to determine these factors.
The following data are used in the capital acquisition model for FY
1997: the March 8, 1996 update of the cost reports for PPS-IX (cost
reporting periods beginning in FY 1992), PPS-X (cost reporting periods
beginning in FY 1993) and PPS-XI (cost reporting periods beginning in
FY 1994), the January 1, 1996 update of the provider-specific file, and
the March 1994 update of the intermediary audit file. The available
data still lack certain items that were required for the determination
of budget neutrality, including each hospital's projected new capital
costs for each year, its projected old capital costs for each year, and
the projected obligated capital amounts that will be put in use for
patient care services and recognized as old capital each year.
Since hospitals under alternative payment system waivers (that is,
hospitals in Maryland) are currently excluded from the capital
prospective payment system, we excluded these hospitals from our model.
We then developed FY 1992, FY 1993, FY 1994, FY 1995, and FY 1996
hospital-specific rates using the provider-specific file, the
intermediary audit file, and, when available, cost reports. (We used
the cumulative provider-specific file, which includes all updates to
each hospital's records, and chose the latest record for each fiscal
year.) We checked the consistency between the provider-specific file
and the intermediary audit file. We also ensured that the FY 1993
increase in the hospital-specific rate was at least 0.62 percent (the
net FY 1993 update), that the FY 1994 hospital-specific rate was at
least as large as the FY 1993 hospital-specific rate decreased by 2.16
percent (the net FY 1994 update), that the FY 1995 increase in the
hospital-specific rate was at least 0.05 percent (the net FY 1995
update), and that the FY 1996 increase in the hospital-specific rate
was at least 21.10 percent (the net FY 1996 update). We were able to
match hospitals to the files as shown in the following table.
------------------------------------------------------------------------
Number of
Source hospitals
------------------------------------------------------------------------
Provider-Specific File Only................................ 101
Provider-Specific and Audit File........................... 5029
------------
Total................................................ 5130
------------------------------------------------------------------------
Sixty-eight of these hospitals had unusable or missing data. We
were able to backfill a hospital-specific rate for 42 of these
hospitals from the cost reports as shown in the following table.
------------------------------------------------------------------------
Number of
Source hospitals
------------------------------------------------------------------------
PPS-VII Cost Reports....................................... 1
PPS-VIII Cost Reports...................................... 2
PPS-IX Cost Reports........................................ 3
PPS-X Cost Reports......................................... 7
PPS-XI Cost Reports........................................ 29
------------
Total................................................ 42
------------------------------------------------------------------------
We did not have data for 26 hospitals, and had to eliminate them
from the capital analysis. These hospitals likely are new hospitals or
hospitals with very few Medicare admissions. This leaves us with 5104
hospitals and should not affect the precision of the required
adjustment factors.
Next, we determined old and new capital amounts for FY 1992 using
the PPS-IX cost reports as the first source of data. For FY 1993
amounts, we used PPS-IX and PPS-X cost reports as the first source of
data, weighting each cost report by the number of days in FY 1993. For
FY 1994 amounts, we used PPS-X and PPS-XI cost reports as the first
source of data, weighting each cost report by the number of days in FY
1994. We were able to match 5,049 PPS-IX cost reports, 5,062 PPS-X cost
reports, and 4,654 PPS-XI cost reports. In cases where cost reports
could not be matched, we used the provider-specific file for old
capital information. Even in cases where a cost report was available,
the breakout of old and new capital was not always available. In these
cases, we used the old capital amounts and new capital ratios from the
provider-specific file. If these were missing, we derived
[[Page 27585]]
the old capital amount from the hospital-specific rate.
Finally, we used the intermediary audit file to develop obligated
capital amounts. Since the obligated amounts are aggregate projected
amounts, we computed a Medicare capital cost per admission associated
with these amounts. We adjusted the aggregate amounts by the following
factors:
(1) Medicare inpatient share of capital. This was derived from cost
reports and was limited to the Medicare share of total inpatient days.
It was necessary to limit the Medicare share because of data integrity
problems. Medicare share of inpatient days is a reasonably good proxy
for allocating capital. However, it may be understated if Medicare
utilization is high, and may be overstated because it does not reflect
the outpatient share of capital.
(2) Capitalization factor. This factor allocates the aggregate
amount of obligated capital to depreciation and interest amounts.
Consistent with the assumptions in the capital input price index, we
used a 25-year life for fixed capital and a 10-year life for movable
capital, and an average projected interest rate of 6.7 percent. We also
assumed that fixed capital acquisitions are about one-half of total
capital. In conjunction with the useful life and interest rate
assumptions, the resulting capitalized fixed capital is about one-half
of total capitalization. This is consistent with the allocations
between fixed and movable capital found on the cost reports. The ratio
we developed is 0.137, which produces the first year capitalization
based on the aggregate amount.
(3) A divisor of Medicare admissions to derive the capital costs
per discharge amount. Since we must project capital amounts for each
hospital, we continued to use a Monte Carlo simulation to develop these
amounts. (This model is described in detail in the August 30, 1991
final rule (56 FR 43517).) The Monte Carlo simulation is now used only
to project capital costs per discharge amounts for each hospital. We
analyzed the distributions of capital increases, and noted a slightly
negative correlation between the dollar level of capital cost per
admission, and the rate of increase in capital. To determine the rate
of increase in capital cost per admission, we multiplied the lesser of
$3,000 or the capital cost per admission by .00006 and subtracted this
result from 1.2. (Increases for capital levels over $3,000 were not
influenced by the level of capital, so this part of the calculation was
capped at $3,000.) We selected a random number from the normal
distribution, multiplied it by 0.17 (the standard deviation) and added
it to -0.04 (the mean) and then added 1 to create a multiplier. This
random result was multiplied by the previous result to assign a rate of
increase factor which was multiplied by the prior year's capital per
discharge amount to develop a capital per discharge amount for the
projected year.
To model a projected year, we used the old and new capital for the
prior year multiplied by 0.85 (aging factor). The 0.85 aging factor is
the average of changes in capital over its life due to the gradual
decrease in interest payments and the retirement of fully
depreciatiated capital. The aged new and old capital is subtracted from
the projected capital described in the previous paragraph. The
difference represents newly acquired capital. If the hospital has
obligated capital, any increase in ``old'' capital up to the total
amount of obligated capital in FY 1993 and FY 1994 is assigned to
obligated capital. Any remaining obligated capital is assigned to FY
1995 up to the amount of the modeled increase in capital for FY 1995.
Even though obligated capital must be put in use for patient care by
October 1, 1994, the use of the obligated capital may have started late
in FY 1994 with only part of the ``first year'' depreciation and
interest realized in FY 1994. The remainder of the ``first year''
depreciation and interest would be realized in FY 1995. With the
exception of certain hospitals about whom we have information to the
contrary, we assume that hospitals would meet the expiration dates
provided under the obligated capital provision. Hence, no obligated
capital is assigned to years FY 1996 and later. Once obligated capital
is assigned, it is included with the ``old'' capital and is capitalized
into future years as part of ``old'' capital. The on-line obligated
amounts are added to old capital and subtracted from the newly acquired
capital to yield residual newly acquired capital, which is then added
to new capital. The residual newly acquired capital is never permitted
to be less than zero.
Next, we computed the average total capital cost per discharge from
the capital costs that were generated by the model and compared the
results to total capital costs per discharge that we had projected
independently of the model. We adjusted the newly acquired capital
amounts proportionately, so that the total capital costs per discharge
generated by the model match the independently projected capital costs
per discharge.
Once each hospital's capital-related costs are generated, the model
projects capital payments. We use the actual payment parameters (for
example, the case-mix index and the geographic adjustment factor) that
are applicable to the specific hospital.
To project capital payments, the model first assigns the applicable
payment methodology (fully prospective or hold-harmless) to the
hospital. If available, the model uses the payment methodology
indicated in the PPS-IX cost reports or the provider-specific file.
Otherwise, the model determines the methodology by comparing the
hospital's FY 1992 hospital-specific rate to the adjusted Federal rate
applicable to the hospital. The model simulates Federal rate payments
using the assigned payment parameters and hospital-specific estimated
outlier payments. The case-mix index for a hospital is derived from the
FY 1995 MedPAR file using the FY 1997 DRG relative weights published in
this proposed rule. The case-mix index is increased each year after FY
1995 based on analysis of past experiences in case-mix increases.
We analyzed the case-mix increases for the recent past and found
that case-mix increases have decelerated to about 1.53 percent in FY
1992, 0.80 percent in FY 1993, and 0.75 percent in FY 1994. It appears
that the case-mix increase for FY 1995 accelerated to around 1.6
percent. Early indications show that FY 1996 case-mix is increasing at
FY 1995 level, around 1.6 percent. It appears that the deceleration of
case-mix increases in FY 1993 and FY 1994 were anomalous, rather than
the beginning of a trend. Therefore, in the model we are using the
recent experience and have used a case-mix increase of 1.6 percent in
FY 1995 and a projected case-mix increase of 1.6 percent in both FY
1996 and FY 1997. (Since we are using FY 1995 cases for our analysis,
the FY 1995 increase in case mix has no effect on projected capital
payments.)
Changes in geographic classification and revisions to the hospital
wage data used to establish the hospital wage index affect the
geographic adjustment factor. Changes in the DRG classification system
and the relative weights affect the case-mix index.
Section 1886(g)(1)(A) of the Act requires that, for discharges
occurring after September 30, 1993, the unadjusted standard Federal
rate be reduced by 7.4 percent. Consequently, the model reduces the
unadjusted standard Federal rate by 7.4 percent effective in FY 1994.
Since budget neutrality expires effective with FY 1996, this adjustment
affects the adjusted Federal rate starting in FY 1996.
[[Page 27586]]
Section 412.308(c)(4)(ii) requires that the estimated aggregate
payments for the fiscal year, based on the Federal rate after any
changes resulting from DRG reclassifications and recalibration and the
geographic adjustment factor, equal the estimated aggregate payments
based on the Federal rate that would have been made without such
changes. For FY 1996, the budget neutrality adjustment factor was
1.0025. To determine the factor for FY 1997, we first determined the
portion of the Federal rate that would be paid for each hospital in FY
1997 based on its applicable payment methodology. Using our model, we
then compared estimated aggregate Federal rate payments based on the FY
1996 DRG relative weights and the FY 1996 geographic adjustment factor
to estimated aggregate Federal rate payments based on the FY 1997
relative weights and the FY 1997 geographic adjustment factor. In
making the comparison, we held the FY 1997 Federal rate portion
constant and set the other budget neutrality adjustment factor and the
exceptions reduction factor to 1.00. We determined that to achieve
budget neutrality for the changes in the geographic adjustment factor
and DRG classifications and relative weights, an incremental budget
neutrality adjustment of 0.9992 for FY 1997 should be applied to the
previous cumulative FY 1996 adjustment of 1.0025 (the product of the FY
1993 incremental adjustment of 0.9980, the FY 1994 incremental
adjustment of 1.0053, the FY 1995 incremental adjustment of 0.9998, and
the FY 1996 incremental adjustment of 0.9994), yielding a cumulative
adjustment of 1.0017 through FY 1997.
The methodology used to determine the recalibration and geographic
(DRG/GAF) budget neutrality adjustment factor is similar to that used
in establishing budget neutrality adjustments under the prospective
payment system for operating costs. One difference is that under the
operating prospective payment system, the budget neutrality adjustments
for the effect of geographic reclassifications are determined
separately from the effects of other changes in the hospital wage index
and the DRG relative weights. Under the capital prospective payment
system, there is a single DRG/GAF budget neutrality adjustment factor
for changes in the geographic adjustment factor (including geographic
reclassification) and the DRG relative weights. In addition, there is
no adjustment for the effects that geographic reclassification has on
the other payment parameters, such as the payments for serving low
income patients or the large urban add-on.
In addition to computing the DRG/GAF budget neutrality adjustment
factor, we used the model to simulate total payments under the
prospective payment system.
Additional payments under the exceptions process are accounted for
through a reduction in the Federal and hospital-specific rates.
Therefore, we used the model to calculate the exceptions reduction
factor. This exceptions reduction factor ensures that aggregate
payments under the capital prospective payment system, including
exceptions payments, are projected to equal the aggregate payments that
would have been made under the capital prospective payment system
without an exceptions process. Since changes in the level of the
payment rates change the level of payments under the exceptions
process, the exceptions reduction factor must be determined through
iteration.
In the August 30, 1991 final rule (56 FR 43517), we indicated that
we would publish each year the estimated payment factors generated by
the model to determine payments for the next 5 years. The table below
provides the actual factors for FY 1992, FY 1993, FY 1994, FY 1995, FY
1996, the proposed FY 1997 factor, and the estimated factors that would
be applicable through FY 2001. We caution that, except with respect to
FY 1992, FY 1993, FY 1994, FY 1995 and FY 1996, these are estimates
only, and are subject to revisions resulting from continued
methodological refinements, more recent data, and any payment policy
changes that may occur. In this regard, we note that in making these
projections we have assumed that the cumulative DRG/GAF adjustment
factor will remain at 1.0017 for FY 1997 and later because we do not
have sufficient information to estimate the change that will occur in
the factor for years after FY 1997.
The projections are as follows:
----------------------------------------------------------------------------------------------------------------
Federal
Update Exceptions Budget rate (after
Fiscal year factor reduction neutrality outlier)
factor factor reduction)
----------------------------------------------------------------------------------------------------------------
1992........................................................ N/A 0.9813 0.9602 415.59
1993........................................................ 6.07 .9756 .9162 \1\ 417.29
1994........................................................ 3.04 .9485 .8947 \2\ 378.34
1995........................................................ 3.44 .9734 .8432 \3\ 376.83
1996........................................................ 1.20 .9849 N/A \4\ 461.96
1997........................................................ 1.00 .9393 N/A \5\ 441.84
1998........................................................ 1.00 .9161 N/A 435.23
1999........................................................ 1.00 .9228 N/A 442.80
2000........................................................ 1.10 .9155 N/A 444.13
2001........................................................ 1.10 N/A6 N/A 490.46
----------------------------------------------------------------------------------------------------------------
\1\ Note: Includes the DRG/GAF adjustment factor of 0.9980 and the change in the outlier adjustment from 0.9497
in FY 1992 to 0.9496 in FY 1993.
\2\ Note: Includes the 7.4 percent reduction in the unadjusted standard Federal rate. Also includes the DRG/GAF
adjustment factor of 1.0033 and the change in the outlier adjustment from 0.9496 in FY 1993 to 0.9454 in FY
1994.
\3\ Note: Includes the DRG/GAF adjustment factor of 1.0031 and the change in the outlier adjustment from 0.9454
in FY 1994 to 0.9414 in FY 1995.
\4\ Note: Includes the the transfer adjustment of .9972. Also includes the DRG/GAF adjustment factor of 1.0025
and the change in the outlier adjustment from 0.9414 in FY 1995 to 0.9536 in FY 1996.
\5\ Note: Includes the DRG/GAF adjustment factor of 1.0017 and the change in the outlier adjustment from 0.9536
in FY 1996 to 0.9476 in FY 1997. Future adjustments are, for purposes of this projection, assumed to remain at
the same level.
\6\ Note: We are unable to estimate exceptions payments for the year under the special exceptions provision
(Sec. 412.348(g) of the regulations) because the regular exceptions provision (Sec. 412.348(e)) expires.
[[Page 27587]]
Appendix C: Rebased Market Basket Data Sources I. Data Sources Used To
Determine the Market Basket Relative Weights and Choice of Price Proxy
Variables for the Operating Hospital Input Price Indexes
As discussed in section IV of the preamble to this proposed rule,
we are rebasing and revising the hospital market baskets. This appendix
describes the technical features of the 1992-based indexes that we are
proposing in this rule. For both the prospective payment and excluded
hospital market baskets, the differences between the proposed 1992-
based market basket and the previous 1987-based market basket are
noted. In the September 4, 1990 final rule (55 FR 36170), we discussed
in detail the 1987-based hospital market baskets.
We present this description of the hospital operating market
baskets in three steps:
A synopsis of the structural differences between the 1987-
based market baskets and the proposed 1992-based market baskets.
A description of the methodology used to develop the cost
category weights in the 1992-based market baskets, making note of the
differences from the methodology used to develop the 1987-based market
baskets.
A description of the data sources used to measure price
change for each component of the 1992-based market baskets, making note
of the differences from the price proxies used in the 1987-based
hospital market baskets.
A. Synopsis of Structural Changes Adopted in the Rebased 1992 Operating
Hospital Market Baskets
Three major structural differences exist between the 1987-based and
the proposed 1992-based operating hospital market baskets.
The proposed hospital market baskets are based on more
recent hospital expenditure data. The 1987-based market baskets
contained skeletal cost shares that were derived from the 1987 cost
data from the 1988 Annual Survey of the American Hospital Association
(AHA). The 1992-based market baskets use data from the hospital cost
reports for cost reporting periods beginning on or after October 1,
1991 and before October 1, 1992.
Some cost categories have been combined, namely Fuel, Oil,
Coal, and Other Fuel with Motor Gasoline, and Blood Services with
Chemicals. These category mergers reflect the Bureau of Economic
Analysis (BEA) reclassification decisions in the 1987 update of the BEA
Input-Output Tables.
In the proposed 1992-based market basket, the sample of
excluded hospitals is restricted to more closely reflect the average
Medicare length of stay in excluded hospitals. We have used cost report
data for excluded hospitals from only those hospitals in which the
Medicare average length of stay is within 15 percent of the total
average length of stay to more accurately reflect the structure of
costs for Medicare cases. This is a change from the FY 1987-based
market basket, for which data from all excluded hospitals were used.
B. Methodology for Developing the Cost Category Weights
Cost category weights for the 1992-based market baskets were
developed in four stages. First, base weights for three (Wages and
Salaries, Employee Benefits, Pharmaceuticals) of the six main
categories were derived from the 1992 Medicare cost reports for
operating costs. Second, the weight for Nonmedical Professional Fees
was developed by subtracting Medical Professional Fees reported in the
Hospital Cost Report Information System (HCRIS) file from AHA Annual
Survey Total Professional Fees to obtain Nonmedical Professional Fees,
and the weight for Professional Liability Insurance was developed using
1989 HCRIS data trended forward to 1992, using the relative importance
values in the previous market baskets. Third, the sum of Wages and
Salaries, Employee Benefits, Pharmaceuticals, Nonmedical Professional
Fees, and Professional Liability Insurance was subtracted from total
expenses to obtain All Other Expenses. Finally, the weight for All
Other Expenses was divided into subcategories using cost shares from
the 1987 Input-Output Table for the hospital industry, produced by the
U.S. Department of Commerce, Bureau of Economic Analysis, aged to 1992
using price changes. We will incorporate 1992 data from the U.S.
Department of Commerce into the final market basket if the data are
released in time to be analyzed in developing the final rule.
Below, we describe the source of the six main category weights and
their subcategories in the 1992-based market baskets. We make note of
the differences between the methodologies used to develop the 1987-
based and the 1992-based market baskets.
1. Wages and Salaries: The cost weight for the Wages and Salaries
category was derived using the 1992 Medicare cost reports. Contract
Labor, which is also derived from the 1992 Medicare cost reports, is
split between the Wages and Salaries and Employee Benefits cost
categories, using the relationship for employed workers. Examples of
Contract Labor are registered nurses and workers in hospital food
service or security who are employed and paid by firms that contract
for their work with the hospital. The Wages and Salaries cost category
was disaggregated into nine occupational subcategories (professional
and technical, managers and administration, sales, clerical, craft and
kindred, operatives excluding transport, transport equipment
operatives, nonfarm laborers and service workers) to reflect the mix of
occupational inputs used by hospitals. The Contract Labor wages and
salaries component was allocated proportionally to Professional-
Technical and Service occupations. The 1987-based weights were
developed from the 1987 Current Population Survey, while the 1992-based
weights were developed from the 1992 Current Population Survey.
2. Employee Benefits: The cost weight for the employee benefits
category was derived from the 1992 cost reports. Like wages and
salaries, the employee benefit weight in each 1992-based market basket
is a composite of nine labor subcategories. The employee benefits
categories in the 1987-based market baskets were developed from the
1987 AHA Annual Survey and used the 1987 Current Population Survey. In
1987 Contract Labor's implied fringe benefits were allocated
proportionally to Professional and Technical occupations, while in 1992
they were allocated to Professional-Technical and Service occupations.
3. Nonmedical Professional Fees: The cost weight for the nonmedical
professional fees category was derived from the 1992 Medicare Cost
Reports and AHA Annual Survey data. Total professional fees were split
into the subcategories medical and other (nonmedical) fees using AHA
Total Professional Fees minus HCRIS Medical Professional Fees to equal
Nonmedical Professional Fees. The 1987-based nonmedical professional
fees cost category was derived from the 1987 AHA Annual Survey and
American Medical Association (AMA) data. It was split into the
subcategories medical and other fees using data derived from the
American Medical Association. The medical professional fees category is
excluded from the hospital market basket since it is paid under
Medicare Part B.
4. Professional Liability Insurance: The 1987-based market baskets
have weights for professional liability insurance that were derived
from the June 30 and December 31, 1987 HAS/Monitrend surveys. The cost
weight for
[[Page 27588]]
the 1992-based professional liability insurance category was derived
from 1989 HCRIS cost shares trended to 1992 using the change in the
relative importance factor for professional liability insurance
(malpractice) from the previous 1987-based prospective payment hospital
and excluded hospital market baskets.
5. Utilities: For the 1987-based market baskets, the cost weight
for utilities was derived by extrapolating the 1985 AHA Annual Survey
utilities cost weight forward to 1987 using the rate of growth in the
HAS/Monitrend cost weight for utilities between 1985 and 1987. The 1987
Utility subcategory weights were aged from their 1982-based index
subcategory weights using price changes from 1982 to 1987. The 1992-
based market basket cost weights for the subcategories (fuel, oil and
gasoline; electricity; natural gas; and water and sewage) were derived
from the Bureau of Economic Analysis' 1987 Input-Output table for the
hospital industry, aged forward to 1992 by price changes and summed to
a weight for utilities.
6. All Other Goods and Services: The all other goods and services
category has more subcategories than any other market basket category.
Goods found in this category include: direct service food, contract
service food, pharmaceuticals, chemicals, medical instruments, photo
supplies, rubber and plastics, paper products, apparel, machinery and
equipment and miscellaneous products. Services found in this category
include: business services, computer services, transportation and
shipping, telephone, postage, other labor-intensive services, and other
nonlabor-intensive services. The share for pharmaceuticals was derived
from the 1992 Medicare cost reports. Relative shares for the other
subcategories were derived from the 1987 Bureau of Economic Analysis'
Input-Output table for the hospital industry and were aged forward to
1992 using price changes. As noted above, if more recent U.S.
Department of Commerce data become available for these categories and
we have time to analyze these data before the publication of the final
rule, they will be incorporated into the final market baskets.
C. Price Proxies Used to Measure Cost Category Growth
1. Wages and Salaries: For measuring price growth in the 1992-based
market basket, 10 price proxies are applied to the 9 occupational
subcategories within the wages and salaries component. As in the 1987-
based market basket, the professional and technical subcategory was
split in half. An Employee Cost Index (ECI) for hourly wages paid to
civilian hospital workers was applied to one half. An ECI of hourly
wages and salaries paid to professional and technical workers in
private industry was applied to the other half of the professional and
technical component. The other eight occupations subcategories of the
wages and salaries component were proxied using ECIs for wages and
salaries for private industry workers in their respective occupational
categories.
2. Employee Benefits: The 1992-based hospital market baskets use
occupation-specific ECIs for employee benefits. The distribution of
weights and price proxies is the same as for wages and salaries
discussed above, but occupation-specific employee benefit ECIs replace
occupation-specific wages and salaries ECIs. The components are summed
into a composite index, just as was done for the 1987-based market
basket.
3. Nonmedical Professional Fees: The ECI for compensation for
professional and technical workers in private industry is applied to
this category. This is a revision from the 1987-based market basket in
which the ECI for wages and salaries for professional and technical
workers in private industry was used.
4. Fuel, Oil, and Gasoline: The percentage change in the price of
refined petroleum products as measured by the Producer Price Index
(PPI) (Commodity Code #057) was applied to this component. This is a
revision from the 1987-based indexes in which the PPIs for Light Fuel
Oil (Commodity Code #0573) and Gasoline (Commodity Code #0571) were
used.
5. Electricity: The percentage change in the price of commercial
electric power as measured by the PPI (Commodity Code #0542) was
applied to this component. This is a revision from the 1987-based
indexes in which the PPI for industrial power (Commodity Code #0543)
was used.
6. Natural Gas: The percentage change in the price of gas fuels as
measured by the PPI (Commodity Code #0552) was applied to this
component. This is a revision from the 1987-based indexes in which the
PPI for Natural Gas (Commodity Code #0531) was used.
7. Water and Sewerage: The percentage change in the price of water
and sewerage maintenance as measured by the Consumer Price Index (CPI)
for all urban consumers was applied to this component. The same price
measure was used in the 1987-based market baskets.
8. Professional Liability Insurance: The percentage change in the
hospital professional liability insurance price as estimated by
hospital industry professional liability insurance premium increase was
applied to this component. The same price measure was used in the 1987-
based market baskets.
9. Pharmaceuticals: The percentage change in the price of ethical
preparations as measured by the PPI (Commodity Code #0635) was applied
to this variable. The same price measure was used in the 1987-based
market baskets.
10. Food, Direct Purchases: The percentage change in the price of
processed foods and feeds as measured by the PPI (Commodity Code #02)
was applied to this component. The same price measure was used in the
1987-based market baskets.
11. Food, Contract Services: The percentage change in the price of
food purchased away from home as measured by the CPI for all urban
consumers was applied to this component. The same price measure was
used in the 1987-based market baskets.
12. Chemicals: The percentage change in the price of industrial
chemical products as measured by the PPI (Commodity Code #061) was
applied to this component. The same price measure was used in the 1987-
based market baskets.
13. Surgical and Medical Equipment: The percentage change in the
price of medical and surgical instruments as measured by the PPI
(Commodity Code #1562) was applied to this component. The same price
measure was used in the 1987-based market baskets.
14. Photographic Supplies: The percentage change in the price of
photographic supplies as measured by the PPI (Commodity Code #1542) was
applied to this component. The same price measure was used in the 1987-
based market baskets.
15. Rubber and Plastics: The percentage change in the price of
rubber and plastic products as measured by the PPI (Commodity Code #07)
was applied to this component. The same price measure was used in the
1987-based market baskets.
16. Paper Products: The percentage change in the price of converted
paper and paperboard products as measured by the PPI (Commodity Code #
0915) was used. This is a revision from the 1987-based indexes in which
a weighted average of the percentage change in the price of converted
paper and paperboard products and the percentage change in the price of
paper excluding newsprint and packaging paper (Commodity Code #091301)
was used.
[[Page 27589]]
17. Apparel: The percentage change in the price of apparel as
measured by the PPI (Commodity Code #381) was applied to this
component. This is a revision from the 1987-based indexes in which the
PPI for textile house furnishings (Commodity Code #0382) was used.
18. Minor Machinery and Equipment: The percentage change in the
price of machinery and equipment as measured by the PPI (Commodity Code
#11) was applied to this component. The same price measure was used in
the 1987-based market baskets.
19. Miscellaneous Products: The percentage change in the price of
all finished goods as measured by the PPI was applied to this
component. The same price measure was used in the 1987-based market
baskets.
20. Business Services: The ECI for compensation for workers in the
business services industry was applied to this component. This is a
revision from the 1987-based indexes in which the percentage change in
the AHE for wages and salaries for production and nonsupervisory
workers in the business services industry as measured by the Bureau of
Labor Statistics (SIC Code 73) was used.
21. Computer and Data Processing Services: The percentage change in
the AHE of production and nonsupervisory workers engaged in firms
furnishing computer data processing services (SIC Code 737) was applied
to this component. The same price measure was used in the 1987-based
market baskets.
22. Transportation and Shipping: The percentage change in the
transportation component of the CPI for all urban consumers was applied
to this component. The same price measure was used in the 1987-based
market baskets.
23. Telephone: The percentage change in the price of telephone
services as measured by the CPI for all urban consumers was applied to
this component. The same price measure was used in the 1987-based
market baskets.
24. Postage: The percentage change in the price of postage as
measured by the CPI for all urban consumers was applied to this
component. The same price measure was used in the 1987-based market
baskets.
25. All Other Services, Labor Intensive: The percentage change in
the ECI for compensation paid to service workers employed in private
industry was applied to this component. This is a revision from the
1987-based indexes in which the ECI for wages and salaries paid to
service workers employed in private industry was used.
26. All Other Services, Nonlabor Intensive: The percentage change
in the all-items component of the CPI for all urban consumers was
applied to this component. The same price measure was used in the 1987-
based market baskets.
For further discussion of the rationale for choosing specific price
proxies, we refer the reader to the September 3, 1986 final rule (51 FR
31582).
II. Data Sources Used to Determine the Cost Category Weights and
Vintage Weights, and Choices of Price Proxy Variables for the Hospital
Capital Input Price Index
In the preamble to this proposed rule, we discuss the rebasing of
the capital input price index (CIPI). This appendix describes certain
technical features of the 1992-based index that we are proposing in
this rule, as well as differences between the proposed 1992-based CIPI
and the current 1987-based CIPI. We discussed the 1987-based CIPI in
the September 1, 1995 final rule (60 FR 45817.)
This discussion has the following three parts:
A synopsis of the differences between the 1987-based CIPI
and the proposed 1992-based CIPI.
A description of the methodology used to develop the cost
category weights and vintage weights in the 1992-based CIPI, making
note of the differences from the methodology used to develop the 1987-
based CIPI.
A description of the data sources used to measure price
change for each component of the 1992-based CIPI, making note of the
differences from the price proxies used in the 1987-based CIPI.
A. Synopsis of Changes Adopted in the Rebased 1992 CIPI
We made no structural changes in the 1992-based CIPI. The only
major change is the use of more recent hospital capital expenditure
data in the proposed 1992-based CIPI.
The 1987-based CIPI contained cost category weights that were
derived from 1987 Medicare cost report data and the 1987 Annual Survey
of the AHA. The 1992-based CIPI uses data from the hospital Medicare
cost reports for cost periods beginning between October 1, 1991 and
September 30, 1992. The 1992-based CIPI also uses data from the 1992
Annual Survey of the AHA.
The 1987-based CIPI contained vintage weights that were derived
from 1987 Medicare cost report data, the 1963-1987 Panel Survey of the
AHA, and the 1980-1989 Securities Data Corporation data on hospital
bonds. The 1992-based CIPI uses data from the 1992 Medicare cost
reports, the 1963-1992 Panel Survey of the AHA, and 1980-1992
Securities Data Corporation data on hospital bonds.
B. Methodology for Developing Cost Category Weights and Vintage Weights
for the 1992-based CIPI
There are five cost categories in the CIPI: building and fixed
equipment depreciation, movable equipment depreciation, capital-related
interest expense from government/nonprofit debt instruments, capital-
related interest expense from for-profit debt instruments, and other
capital-related expenses, such as taxes and insurance. The methodology
for developing each of these cost category weights is described below:
1. Building and Fixed Equipment Depreciation: The 1992-based cost
weight for building and fixed equipment depreciation was derived using
the 1992 Medicare cost reports. The proportion of lease expenses
attributable to building and fixed equipment was included in the cost
weight based on the proportion of overall capital expenses allocated to
building and fixed equipment depreciation. The 1987-based weight was
developed from the 1987 Medicare cost reports and the 1987 AHA Annual
Survey.
2. Movable Equipment Depreciation: The 1992-based cost weight for
movable equipment depreciation was derived using the 1992 Medicare Cost
Reports. The proportion of lease expenses attributable to movable
equipment was included in the cost weight based on the proportion of
overall capital expenses allocated to movable equipment depreciation.
The 1987-based weight was developed from the 1987 Medicare cost reports
and the 1987 AHA Annual Survey.
3. Government/Nonprofit Interest: The 1992-based cost weight for
government/nonprofit interest was derived using the 1992 AHA Annual
Survey data. The government/nonprofit interest is 85 percent of total
interest, reflecting the relative debts of the government/nonprofit
hospital sector and the for-profit hospital sector. The proportion of
lease expenses attributable to government/nonprofit interest was
included in the cost weight based on the proportion of overall capital
expenses allocated to government/non-profit interest expense. The 1987-
based weight was developed from the 1987 AHA Annual Survey.
4. For-Profit Interest: The 1992-based cost weight of for-profit
interest was
[[Page 27590]]
derived using the 1992 AHA Annual Survey data. The for-profit interest
is 15 percent of total interest, reflecting the relative debts of the
government/nonprofit hospital sector and the for-profit hospital
sector. The proportion of lease expenses attributable to for-profit
interest was included in the cost weight based on the proportion of
overall capital expenses allocated to for-profit interest expense. The
1987-based weight was developed from the 1987 AHA Annual Survey.
5. Other Capital-Related Expenses: The 1992-based cost weight for
other capital-related expenses was derived using 1992 Medicare cost
reports. The proportion of lease expenses attributable to other
capital-related expenses was included in the cost weight based on the
proportion of overall capital expenses allocated to other capital-
related expenses. The 1987-based weight was developed from the 1987
Medicare cost reports and the 1987 Capital Expenditure Survey.
There are three sets of vintage weights in the CIPI: building and
fixed equipment depreciation, movable equipment depreciation, and
interest expense. The methodology for developing each of these vintage
weights is described below.
1. Building and Fixed Equipment: The 1992-based building and fixed
equipment vintage weights were derived from the 1992 Medicare cost
reports and the 1963-1992 AHA Panel Survey. The 1987-based weights were
developed from the 1987 Medicare cost reports and the 1963-1987 AHA
Panel Survey.
2. Movable Equipment: The 1992-based movable equipment vintage
weights were derived from the 1992 Medicare cost reports and the 1963-
1992 AHA Panel Survey. The 1987-based weights were developed from the
1987 Medicare cost reports and the 1963-1987 AHA Panel Survey.
3. Capital-Related Interest: The 1992-based movable equipment
vintage weights were derived from the 1980-1992 Securities Data
Corporation data on hospital bonds and the 1963-1992 AHA Panel Survey.
The 1987-based weights were developed from the 1980-1989 Securities
Data Corporation data on hospital bonds and the 1963-1987 AHA Panel
Survey.
C. Price Proxies Used to Measure Cost Category Growth in the CIPI
1. Building and Fixed Equipment Depreciation: The percentage change
in the vintage-weighted price of building and fixed equipment
depreciation as measured by the Boeckh institutional construction index
was applied to this category in the 1992-based CIPI. The same price
proxy was used in the 1987-based CIPI.
2. Movable Equipment Depreciation: The percentage change in the
vintage-weighted price of movable equipment depreciation as measured by
the Producer Price Index (PPI) for machinery and equipment was applied
to this category in the 1992-based CIPI. The same price proxy was used
in the 1987-based CIPI.
3. Government/Nonprofit Interest Expense: The percentage change in
the vintage-weighted price of government/nonprofit interest expense as
measured by the Average yield on Domestic Municipal Bonds from the Bond
Buyer index of 20 bonds was applied to this category in the 1992-based
CIPI. The same price proxy was used in the 1987-based CIPI.
4. For-Profit Interest Expense: The percentage change in the
vintage-weighted price of for-profit interest expense as measured by
the Average yield on Moody's AAA Bonds was applied to this category in
the 1992-based CIPI. The same price proxy was used in the 1987-based
CIPI.
5. Other Capital-Related Expenses: The percentage change in the
price of other capital-related expenses as measured by the CPI for all
urban consumers for residential rent was applied to this category in
the 1992-based CIPI. The same price proxy was used in the 1987-based
CIPI.
We provided more detailed discussion of the rationale for the
choice of these price proxies in the June 2, 1995 proposed rule (60 FR
29227) and in the September 1, 1995 final rule (60 FR 45815).
The Honorable Albert Gore, Jr.
President of the Senate
Washington, D.C. 20510
Dear Mr. President: Section 1886(e)(3)(B) of the Social Security
Act (the Act) requires me to report to Congress the initial estimate
of the applicable percentage increase in inpatient hospital payment
rates for Federal Fiscal Year (FY) 1997 that I will recommend for
hospitals subject to the Medicare prospective payment system (PPS)
and for hospitals and units excluded from PPS. This submission
constitutes the required report.
Current law mandates an update for all PPS hospitals of the
market basket rate of increase minus 0.5 percentage points. The
President's FY 1997 budget includes an update for PPS hospitals in
both large urban areas and other areas equal to the market basket
rate of increase minus 1.5 percentage points. The President's FY
1997 budget estimated the PPS market basket rate of increase for FY
1997 to be 3.6 percent. Based on this estimate, we recommend an
update for hospitals in both large urban and other areas of 2.1
percent. However, recent data from ProPAC and other sources suggest
that the final PPS market basket rate of increase for FY 1997 will
be lower.
Sole community hospitals (SCHs) are the sole source of care in
their area and are afforded special payment protection to maintain
access to services for Medicare beneficiaries. SCHs are paid the
higher of a hospital-specific rate or the Federal PPS rate. Current
law mandates an update for sole community hospitals of the market
basket rate of increase minus 0.5 percentage points. Consistent with
the President's FY 1997 budget, we recommend an update to hospital-
specific rates equal to the increase for all PPS hospitals; that is,
the market basket rate of increase of 3.6 percent minus 1.5
percentage points, or 2.1 percent.
Hospitals and distinct part hospital units excluded from PPS are
paid based on their reasonable costs subject to a limit under the
Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current
law mandates an update for all hospitals and distinct part hospital
units excluded from PPS equal to the rate of increase in the
excluded hospital market basket minus 1.0 percentage point, although
the update can be higher for certain hospitals and units with costs
that are greater than their target amounts. The President's FY 1997
budget incorporates an increase in the TEFRA limit equal to the rate
of increase in the excluded hospital market basket (3.6 percent)
minus 1.5 percentage points. Therefore, we recommend an increase in
the TEFRA limit of 2.1 percent.
My recommendation for the updates is based on cost projections
used in the President's FY 1997 budget. A final recommendation on
the appropriate percentage increases for FY 1997 will be made nearer
the beginning of the new Federal Fiscal Year based on the most
current market basket projection available at that time. The final
recommendation will incorporate our analysis of the latest estimates
of all relevant factors, including recommendations by the
Prospective Payment Assessment Commission (ProPAC). We currently
expect that the final estimate of the market basket rate of increase
will be lower than the estimate used in the President's FY 1997
budget.
Section 1886(d)(4)(C)(iv) of the Act also requires that I
include in my report recommendations with respect to adjustments to
the diagnosis-related group (DRG) weighting factors. At this time I
do not anticipate recommending any adjustment to the DRG weighting
factors for FY 1997.
I am pleased to provide this recommendation to you. I am also
sending a copy of this letter to the Speaker of the House of
Representatives.
Sincerely,
Donna E. Shalala
The Honorable Newt Gingrich
Speaker of the House of Representatives
Washington, D.C. 20515
Dear Mr. Speaker: Section 1886(e)(3)(B) of the Social Security
Act (the Act) requires me to report to Congress the initial estimate
of the applicable percentage increase in inpatient hospital payment
rates for Federal Fiscal Year (FY) 1997 that I will recommend for
hospitals subject to the Medicare prospective payment system (PPS)
and for hospitals and units excluded from PPS. This submission
constitutes the required report.
[[Page 27591]]
Current law mandates an update for all PPS hospitals of the
market basket rate of increase minus 0.5 percentage points. The
President's FY 1997 budget includes an update for PPS hospitals in
both large urban areas and other areas equal to the market basket
rate of increase minus 1.5 percentage points. The President's FY
1997 budget estimated the PPS market basket rate of increase for FY
1997 to be 3.6 percent. Based on this estimate, we recommend an
update for hospitals in both large urban and other areas of 2.1
percent. However, recent data from ProPAC and other sources suggest
that the final PPS market basket rate of increase for FY 1997 will
be lower.
Sole community hospitals (SCHs) are the sole source of care in
their area and are afforded special payment protection to maintain
access to services for Medicare beneficiaries. SCHs are paid the
higher of a hospital-specific rate or the Federal PPS rate. Current
law mandates an update for sole community hospitals of the market
basket rate of increase minus 0.5 percentage points. Consistent with
the President's FY 1997 budget, we recommend an update to hospital-
specific rates equal to the increase for all PPS hospitals; that is,
the market basket rate of increase of 3.6 percent minus 1.5
percentage points, or 2.1 percent.
Hospitals and distinct part hospital units excluded from PPS are
paid based on their reasonable costs subject to a limit under the
Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current
law mandates an update for all hospitals and distinct part hospital
units excluded from PPS equal to the rate of increase in the
excluded hospital market basket minus 1.0 percentage point, although
the update can be higher for certain hospitals and units with costs
that are greater than their target amounts. The President's FY 1997
budget incorporates an increase in the TEFRA limit equal to the rate
of increase in the excluded hospital market basket (3.6 percent)
minus 1.5 percentage points. Therefore, we recommend an increase in
the TEFRA limit of 2.1 percent.
My recommendation for the updates is based on cost projections
used in the President's FY 1997 budget. A final recommendation on
the appropriate percentage increases for FY 1997 will be made nearer
the beginning of the new Federal Fiscal Year based on the most
current market basket projection available at that time. The final
recommendation will incorporate our analysis of the latest estimates
of all relevant factors, including recommendations by the
Prospective Payment Assessment Commission (ProPAC). We currently
expect that the final estimate of the market basket rate of increase
will be lower than the estimate used in the President's FY 1997
budget.
Section 1886(d)(4)(C)(iv) of the Act also requires that I
include in my report recommendations with respect to adjustments to
the diagnosis-related group (DRG) weighting factors. At this time I
do not anticipate recommending any adjustment to the DRG weighting
factors for FY 1997.
I am pleased to provide this recommendation to you. I am also
sending a copy of this letter to the President of the Senate.
Sincerely,
Donna E. Shalala
Appendix E: Recommendation of Update Factors for Operating Cost Rates
of Payment for Inpatient Hospital Services
I. Background
Several provisions of the Social Security Act (the Act) address the
setting of update factors for inpatient services furnished in FY 1997
by hospitals subject to the prospective payment system and those
excluded from the prospective payment system. Section
1886(b)(3)(B)(i)(XII) of the Act sets the FY 1997 percentage increase
in the operating cost standardized amounts equal to the rate of
increase in the hospital market basket minus 0.5 percentage points for
prospective payment hospitals in all areas. Section 1886(b)(3)(B)(iv)
of the Act sets the FY 1997 percentage increase in the hospital-
specific rates applicable to sole community hospitals equal to the rate
set forth in section 1886(b)(3)(B)(i) of the Act, that is, the same
update factor as all other hospitals subject to the prospective payment
system, or the rate of increase in the market basket minus 0.5
percentage points. Section 1886(b)(3)(B)(ii) of the Act sets the FY
1997 percentage increase in the rate of increase limits for hospitals
excluded from the prospective payment system equal to the rate of
increase in the excluded hospital market basket minus the applicable
reduction or, in the case of a hospital in a fiscal year for which the
hospital's update adjustment percentage is at least 10 percent, the
excluded hospital market basket percentage increase. Under section
1886(b)(3)(B)(v) of the Act, a hospital's update adjustment percentage
increase for FY 1997 is the percentage increase by which the hospital's
allowable operating costs of inpatient hospital services recognized
under this title for the cost reporting period beginning in FY 1990
exceed the hospital's target amount for such cost reporting period,
increased for each fiscal year (beginning with FY 1994) by the sum of
any of the hospital's applicable reductions for previous years. The
applicable reduction with respect to a hospital for FY 1997 is the
lesser of 1 percentage point or the percentage point difference between
10 percent and the hospital's update adjustment percentage for FY 1997.
In accordance with section 1886(d)(3)(A) of the Act, we are
proposing to update the standardized amounts, the hospital-specific
rates, and the rate-of-increase limits for hospitals excluded for the
prospective payment system as provided in section 1886(b)(3)(B) of the
Act. Based on the first quarter 1996 forecast of the FY 1997 rebased
market basket increase of 2.7 percent for hospitals subject to the
prospective payment system, the proposed updates in the standardized
amounts are 2.2 percent for hospitals in both large urban and other
areas. The proposed update in the hospital-specific rate applicable to
sole community hospitals is 2.2 percent (that is, the market basket
rate of increase of 2.7 percent minus 0.5 percentage points). The
proposed update for hospitals excluded from the prospective payment
system is based on the percentage increase in the excluded hospital
market basket (currently estimated at 2.7 percent) minus the applicable
reduction factor. The applicable reduction factor is the lesser of 1
percentage point or the percentage point difference between 10 percent
and the hospital's update adjustment percentage. Therefore, for
excluded hospitals, the hospital-specific proposed update can vary
between 1.7 and 2.7 percent.
Sections 1886(e)(2)(A) and (3)(A) of the Act require that the
Prospective Payment Assessment Commission (ProPAC) recommend to the
Congress by March 1, 1996 an update factor that takes into account
changes in the market basket rate of increase index, hospital
productivity, technological and scientific advances, the quality of
health care provided in hospitals, and long-term cost effectiveness in
the provision of inpatient hospital services.
In its March 1, 1996 report, ProPAC recommended update factors to
the standardized amounts equal to the percentage increase in the market
basket minus 0.7 to 2.0 percentage points for hospitals in both large
urban and other areas (Recommendation 10). Based on its market basket
rate of increase estimate of 2.7 percent, ProPAC's recommended update
to the standardized amounts equals 2.0 to 0.7 percent for hospitals in
both large urban and other areas. (ProPAC's market basket is still
using the 1987-based weights.) ProPAC did not make a separate
recommendation for the hospital-specific rates applicable to sole
community hospitals. The components of ProPAC's update factor
recommendations are described in detail in the ProPAC report, which is
published as Appendix F to this document. We discuss ProPAC's
recommendations concerning the update factors and our responses to
these recommendations below.
Section 1886(e)(4) of the Act requires that the Secretary, taking
into
[[Page 27592]]
consideration the recommendations of ProPAC, recommend update factors
for each fiscal year that take into account the amounts necessary for
the efficient and effective delivery of medically appropriate and
necessary care of high quality. Under section 1886(e)(5) of the Act, we
are required to publish the update factors recommended under section
1886(e)(4) of the Act. Accordingly, this appendix provides the
recommendations of appropriate update factors, the analysis underlying
our recommendations, and our responses to the ProPAC recommendations
concerning the update factors.
II. Secretary's Recommendations
Under section 1886(e)(4) of the Act, we are recommending that the
standardized amounts be increased by an amount equal to the market
basket rate of increase minus 1.5 percentage points for hospitals
located in large urban and other areas. We are also recommending an
update of the market basket rate of increase minus 1.5 percentage
points to the hospital-specific rate for sole community hospitals.
These figures are consistent with the President's FY 1997 budget
recommendation, which continues the reductions imposed by section 13501
of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66),
that is, reductions in the hospital market basket of 2.5 percentage
points for FYs 1994 and 1995 and 2.0 percentage points for FY 1996. We
believe these recommended changes in the update factor would ensure
that Medicare acts as a prudent purchaser and provide incentives to
hospitals for increased efficiency, thereby contributing to the
solvency of the Medicare Part A Trust Fund. When the President's budget
was submitted, the market basket rate of increase was projected at 3.6
percent. As noted above, this proposed recommendation is based on the
most recent forecast of the proposed rebased market basket. (See
section IV of the preamble to this proposed rule for a detailed
discussion of the market basket.)
We recommend that hospitals excluded from the prospective payment
system receive an update equal to the percentage increase in the
proposed rebased market basket that measures input price increases for
services furnished by excluded hospitals minus 1.5 percentage points.
That market basket rate of increase is currently forecast at 2.7
percent. Subtracting 1.5 percentage points would result in an update
for hospitals excluded from the prospective payment system of 1.2
percent. This recommendation is consistent with the President's budget,
acknowledging that the market basket rate of increase for these
hospitals also was forecast at 3.6 percent at the time the budget was
submitted.
As required by section 1886(e)(4) of the Act, we have taken into
consideration the recommendations of ProPAC in setting these
recommended update factors. Our responses to the ProPAC recommendations
concerning the update factors are discussed below.
III. ProPAC Recommendation for Updating the Prospective Payment System
Standardized Amounts
For FY 1997, ProPAC's update framework would support an update
between 0.7 percentage points and 2.0 percentage points less than the
increase in the hospital market basket index. The methodology employed
by the Commission in previous years would lead to a recommendation of
about market basket minus 1.5 percentage points, roughly corresponding
to the midpoint of that range. In light of the significant changes
occurring in health care delivery, the Commission believes that the
increase in the prospective payment system rates could be held to
market basket minus 2.0 percentage points for the next year or two.
However, it is concerned about the potential effects of continuing
updates at that level on hospitals' financial health. Low updates over
an extended period of time could affect a hospital's ability to provide
quality care to Medicare beneficiaries, compromise access, and impede
the diffusion of quality-enhancing technological advances.
Based on the market basket estimate of 2.7 percent, ProPAC
recommends that hospitals in large urban and other areas receive an
update between 0.7 to 2.0 percent.
Response: We are recommending an update that is consistent with the
Administration's budget proposal. Our recommendation is that the update
for FY 1997 for prospective payment system hospitals located in large
urban and other areas be equal to the market basket rate of increase
forecast minus 1.5 percentage points. Based on HCFA's current forecast
of the market basket rate of increase (2.7 percent), we recommend an
update for FY 1997 for large urban and other hospitals equal to 1.2
percent. Our recommendation is supported by the following analyses that
measure changes in hospital productivity, scientific and technological
advances, practice pattern changes, and changes in case mix:
Productivity: Service level productivity is defined as the
ratio of total service output to full-time equivalent employees (FTEs).
While we recognize that productivity is a function of many variables
(for example, labor, nonlabor material, and capital inputs), we use a
labor productivity measure since this update framework applies to
operating payment. To recognize that we are apportioning the short run
output changes to the labor input and not considering the nonlabor
inputs, we weight our productivity measure for operating costs by the
share of direct labor services in the market basket rate of increase to
determine the expected effect on cost per case.
Our recommendation for the service productivity component is based
on historical trends in productivity and total output for both the
hospital industry and the general economy, and projected levels of
future hospital service output. ProPAC has also estimated cumulative
service productivity growth to be 4.9 percent from 1985-1989, or 1.2
percent annually. At the same time, the Commission estimates total
output growth at 3.4 percent annually, implying a ratio of service
productivity growth to output growth of 0.35. Our Medicare Provider
Analysis and Review (MedPAR) file analysis indicates total Medicare
service output (charges per admission, adjusted for CPI change)
increased 10.7 percent from 1987-1995, or an approximate average annual
increase of 1.2 percent. Since it is not possible at this time to
develop a productivity measure specific to Medicare patients, we
examined productivity (output per hour) and output (gross domestic
product) for the economy. Depending on the exact time period, annual
changes in productivity range from 0.3 to 0.35 percent of the change in
output (that is, a 1.0 percent increase in output would be correlated
with an 0.3 to 0.35 percent change in output per hour).
Under our framework, the recommended update is based in part on
expected productivity--that is, projected service output during the
year multiplied by the historical ratio of service productivity to
total service output, multiplied by the share of labor in total
operating inputs, as calculated in the hospital market basket rate of
increase. This method estimates an expected labor productivity
improvement in the same proportion to expected total service growth
that has occurred in the past and assumes that, at a minimum, growth in
FTEs changes proportionally to the growth in total service output.
Thus, the recommendation allows for unit productivity to be smaller
than the
[[Page 27593]]
historical averages in years that output growth is relatively low and
higher in years that output growth is larger than the historical trend.
Based on the above estimates from both the hospital industry and the
economy, we have chosen to employ the range of ratios of productivity
change to output change of 0.30 to 0.35.
The expected change in total hospital service output is the product
of projected growth in total admissions (adjusted for outpatient
usage), projected real case-mix growth, and expected quality enhancing
intensity growth, net of expected decline in intensity due to reduction
of cost ineffective practice. Case-mix growth and intensity numbers for
Medicare are used as proxies for those of the total hospital, since
case-mix increases (used in the intensity measure as well) are
unavailable for non-Medicare patients. Thus, expected output growth is
simply the sum of the expected change in intensity (0.0 percent),
projected admissions change (2.7 percent for FY 1997), and projected
real case-mix growth (1.6 percent), or 4.3 percent. The share of direct
labor services in the market basket rate of increase (consisting of
wages, salaries, and employee benefits) is 61.4 percent. Multiplying
the expected change in total hospital service output (4.3 percent) by
the ratio of historical service productivity change to total service
growth of 0.30 to 0.35 and by the direct labor share percentage (0.614)
provides our productivity standard of 0.8 to 0.9 percent.
ProPAC also believes hospitals should be given an incentive for
additional productivity improvement. ProPAC measures productivity as
the ratio of hospital admissions (adjusted for case mix and outpatient
services) per FTE employee (adjusted for changes in skill mix). ProPAC
includes in its productivity measurement the effect of changes in
practice patterns. We treat practice pattern changes as a portion of
our intensity adjustment, described below. ProPAC's latest estimate
indicate that hospital productivity increased as much as 2.3 percent in
1994. Given this improvement, ProPAC believes a productivity adjustment
in the range of -0.7 to -1.2 percentage points would be reasonable in
fiscal year 1997. The adjustment is intended to share productivity
equally between hospitals and Medicare. In the near future, ProPAC
believes there may be even greater productivity improvements, as
hospitals strive to stay competitive and financially viable.
Intensity: We base our intensity standard on the combined
effect of three separate factors: changes in the use of quality
enhancing services, changes in the use of services due to shifts in
within-DRG severity, and changes in the use of services due to
reductions of cost-ineffective practices. For FY 1997, we recommend an
adjustment of 0.0 percent. The basis of this recommendation is
discussed below.
We have no empirical evidence that accurately gauges the level of
quality-enhancing technology changes. Typically, a specific new
technology increases cost in some uses and decreases cost in other
uses. Concurrently, health status is improved in some situations while
in other situations it may be unaffected or even worsened using the
same technology. It is difficult to separate out the relative
significance of each of the cost increasing effects for individual
technologies and new technologies.
The quality enhancing technology component is intended to recognize
the use of services that increase cost but whose value in terms of
enhanced health-status is commensurate with these costs. Such services
may result from technological change, or in some cases, increased use
of existing technologies. The latter recognizes that as cost and
medical effectiveness studies become available, some increased use of
existing, as well as new, services may be warranted.
The component for reduction of cost-ineffective practice recognizes
that some improvements in practice patterns could be made so that the
intensity of services provided is more consistent with the efficient
use of limited resources. That is, improvements could be made so that
the number of services provided during an inpatient stay, and their
complexity, produce an improvement in health status that is consistent
with the cost of care. This component of our update recommendation is
intended to encourage both hospitals and physicians to more carefully
consider the cost-effectiveness of medical care. This component of the
framework also accounts for real within-DRG change, since that should
be directly reflected in the CMI-adjusted growth in real charges per
case.
Following methods developed by HCFA's Office of the Actuary for
deriving hospital output estimates from total hospital charges, we have
developed Medicare-specific intensity measures based on a 5-year
average using FY 1991-1995 MedPAR billing data. Case-mix constant
intensity is calculated as the change in total Medicare charges per
discharge adjusted for changes in the average charge per unit of
service as measured by the Medical CPI hospital component and changes
in real case mix. Thus, in order to measure changes in intensity, one
must measure changes in real case mix.
For FY 1991 and FY 1992, we estimate that 1.0 to 1.4 percent of
observed case-mix increase was real. This estimate is supported by past
studies of case-mix change by the RAND Corporation. The most recent
study was Has DRG Creep Crept Up? Decomposing the Case Mix
Index Change Between 1987 and 1988 by G.M. Carter, J.P.
Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991). The study
suggests that real case-mix change was not dependent on total change,
but was rather a fairly steady 1.0 to 1.5 percent per year. In the past
we have used 1.4 percent as the upper bound because the RAND study did
not take into account that hospitals may have induced doctors to
document medical records more completely in order to improve payment.
For FY 1993 and FY 1994, we assumed that all of the observed case-mix
increases of 0.9 and 0.8 percent, respectively, were real. For FY 1995,
we assumed that all of the observed case-mix increase of 1.6 percent
was real. We note that this assumed increase in real case mix is higher
than our previously assumed upper bound of 1.4 percent. Based on its
analysis of the FY 1995 MedPAR data, the Office of the Actuary has
concluded that the apparent shifting of some cases to the outpatient
setting and activity in the cardiovascular DRGs has contributed to a
higher than expected increase in real case mix.
Given estimates of real case-mix increase of 1.0 percent for FY
1991-1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, and 1.6
percent for FY 1995, we estimate case-mix constant intensity declined
by an average 1.1 percent during FY 1991 through 1995, for a cumulative
decrease of 5.6 percent. If we assume that real case-mix increase was
1.4 percent for FYs 1991 and 1992, 0.9 percent for FY 1993, 0.8 percent
for FY 1994, and 1.6 percent for FY 1995, we estimate case-mix constant
intensity declined by an average of 1.2 percent during FY 1991 through
1994, for a cumulative decrease of 5.9 percent. Since we estimate that
intensity has declined during FY 1991-1995 period, we are recommending
a 0.0 percent intensity adjustment for FY 1997.
Quality Enhancing New Science and Technology: For FY 1997,
ProPAC has computed the adjustment for scientific and technological
advances to be a future-oriented policy target intended to provide
additional funds for hospitals to adopt quality-enhancing, cost
increasing health care innovations.
[[Page 27594]]
While in the past the Commission has included an adjustment ranging
from 0.3 to 1.0 percentage points, the current range is lower because
there is little evidence of significant new cost-increasing advances
ready for implementation. Moreover, the cost-competitive environment
now faced by hospitals may dampen the adoption of new technologies as
they closely evaluate their relative costs and benefits. Therefore, the
Commission recommends an adjustment of 0.1 to 0.6 percentage points for
the increase in operating costs due to scientific and technological
advances.
Change in Case Mix: Our analysis takes into account
projected changes in case mix, adjusted for changes attributable to
improved coding practices. For our FY 1997 update recommendation, we
are projecting a 1.6 percent increase in the case-mix index. We define
real case-mix increase as actual changes in the mix (and resource
requirements) of Medicare patients as opposed to changes in coding
behavior that result in assignment of cases to higher-weighted DRGs but
do not reflect greater resource requirements. For FY 1997, we believe
that real case-mix increase is equal to our projected change in case
mix. We do not see any changes in coding behavior in our projected
case-mix change. Our net adjustment to case-mix change for FY 1997 is
0.0 percentage points.
The -1.0 to -0.9 percent figure used in the ProPAC framework
represents ProPAC's projection for observed case-mix change. ProPAC
projects a 0.8 to 0.9 percentage points increase in real case-mix
change across DRG's and a 0.0 to 0.2 percentage points increase in
within-DRG case-complexity change. ProPAC's net adjustment for case mix
is -0.2 to 0.0 percentage points.
Effect of FY 1995 DRG Reclassification and Recalibration:
We estimate that DRG reclassification and recalibration for FY 1995
resulted in a 0.0 percent increase in the case-mix index when compared
with the case-mix index that would have resulted if we had not made the
reclassification and recalibration changes to the GROUPER. ProPAC does
not make an adjustment for DRG reclassification and recalibration in
its update recommendation.
Correction for Market Basket Forecast Error: The estimated
market basket percentage increase used to update the FY 1995 payment
rates was 3.6 percent. Our most recent data indicate the actual FY 1995
increase was 3.0 percent, reflecting that the actual increase in wages
was lower than projected. The resulting forecast error in the FY 1995
market basket rate of increase is 0.6 percentage points. Under our
update framework, we make a forecast error correction if our estimate
is off by 0.25 percentage points or more. Therefore, we are
recommending an adjustment of -0.6 percentage points to reflect this
overestimation of the FY 1995 market basket rate of increase. The
following is a summary of the update ranges supported by our analyses
compared to ProPAC's framework.
Table 1.--Comparison of FY 1997 Update Recommendations
----------------------------------------------------------------------------------------------------------------
HHS ProPAC
----------------------------------------------------------------------------------------------------------------
Market Basket......................................................... MB MB
Difference Between HCFA & ProPAC Market Baskets....................... ................... -0.1 to 0.0
-----------------------------------------
Subtotal........................................................ MB MB to MB-0.1
=========================================
Policy Adjustment Factors
Productivity.......................................................... -0.9 to -0.8 -1.2 to -0.7
Intensity: 0.0 ...................
Science and Technology............................................ ................... 0.1 to 0.6
Practice Patterns................................................. ................... (\1\)
Real Within DRG Change............................................ ................... (\2\)
-----------------------------------------
Subtotal........................................................ -0.9 to -0.8 -1.1 to -0.1
=========================================
Case-Mix Adjustment Factors
Projected Case-Mix Change......................................... -1.6 -1.0 to -0.9
Real Across DRG Change............................................ 1.6 0.8 to 0.9
Real Within DRG Change............................................ (\3\) 0.0 to 0.2
-----------------------------------------
Subtotal........................................................ 0.0 -0.2 to 0.0
=========================================
Effect of 1995 Reclassification and Recalibration................. 0.0 ...................
Forecast Error Correction............................................. -0.6 -0.6
-----------------------------------------
Total Recommended Update........................................ MB-1.5 to MB-1.4 MB-2.0 to MB-0.7
----------------------------------------------------------------------------------------------------------------
\1\ Included in ProPAC's Productivity Measure.
\2\ Included in ProPAC's Case-Mix Adjustment.
\3\ Included in HHS' Intensity Factor.
The above analysis would support a recommendation that the update
be between market basket minus 1.4 and market basket minus 1.5
percentage points. We are recommending an update of market basket minus
1.5 percentage points, consistent with President Clinton's FY 1997
budget proposal. We also recommend that the hospital-specific rates
applicable to sole community hospitals be increased by the same update,
market basket minus 1.5 percentage points.
V. ProPAC Recommendation for Updating the Rate-of-Increase Limits for
Excluded Hospitals
ProPAC recommends an update factor equal to the market basket rate
of increase minus 0.6 percentage points for excluded hospitals and
units (Recommendation 12). The 0.6 percentage points reduction
represents a
[[Page 27595]]
reduction of 0.6 percentage points to account for the forecast error in
the FY 1995 market basket rate of increase for excluded units, no
increase to reflect the different compensation price proxies used by
ProPAC, and no allowance for new technology. ProPAC believes that major
changes in the excluded hospitals' target amounts should not be made at
this time. Rather, a prospective payment system for excluded hospitals
and units should be implemented as soon as possible.
Response: We recommend that hospitals excluded from the prospective
payment system receive an update equal to the percentage increase in
the market basket that measures input price increases for services
furnished by excluded hospitals minus 1.5 percentage points. The
reduction is consistent with the updates provided under President
Clinton's budget proposal. The market basket rate of increase for
excluded hospitals is currently forecast at 2.7 percent. Subtracting
1.5 percentage points would result in an update of 1.2 percent for
excluded hospitals and units.
As noted by ProPAC, HCFA has contracted with the RAND Corporation
to analyze a classification system for rehabilitation patients that
appears to have the potential to serve as the basis for a prospective
payment system for rehabilitation hospitals and units. However, even if
this classification system is found to be suitable, it would be several
years before we could fully implement any prospective payment system
for these facilities. In addition, we have been less successful in our
pursuit of a suitable classification system for the other types of
excluded hospitals. Therefore, as an interim measure, the President's
budget contains a proposal to rebase the target amounts for excluded
hospitals and units on more recent cost data. Changes would also be
made to the conditions under which facilities would receive additional
payment when they exceed their limits. Incentive payments for
facilities whose costs are below their target amounts would be
eliminated.
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[FR Doc. 96-13613 Filed 5-30-96; 8:45 am]
BILLING CODE 4120-01-C
